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Effective March 1, 2004 - All Adult Care Homes (including assisted living/residential health care facilities, boarding care homes, home plus facilities and adult day care) are now managed by The Kansas Department on Aging
Licensure and Certification and Evaluation Commission
503 S. Kansas Ave
Topeka, KS 66603-3404
Phone: 785-296-4986

This page makes available for direct download as Portable Document Format (.pdf) files (see note above) state licensure and related forms and instructions for health care providers regulated by the Bureau of Health Facilities (BHF). Additionally this page provides links to Medicare certification forms and related information which may be applicable to health care providers seeking Medicare reimbursement. A general link to forms of the Centers For Medicare & Medicaid Services (formerly Health Care Financing Administration) is as follows: http://cms.hhs.gov/forms/ Links to specific provider/supplier enrollment forms and associated information can be found in the sections below. Please consult appropriate state laws and state regulations as well as federal laws and federal regulations for definitions and other requirements for the provider types discussed on this page. Questions about state licensure/Medicare certification forms for KDHE regulated providers can be directed to: Hospital and Medical Program at 785-296-1240.

Fee Payment

Submission of many of the state licensure forms below also requires submission of an accompanying fee. Fees must be paid by either check, money order or credit card payment authorization made payable to the Kansas Department of Health and Environment (KDHE).

KDHE currently accepts only the Discover/Novus credit card. Use of this credit card for payment to KDHE entails a convenience fee of 2.5% to recover costs associated with acceptance of the credit card. Payments made via check or money order are not subject to this fee. To make Discover card payments to KDHE, use this form.

Medical Care Facilities: (Hospitals & Ambulatory Surgical Centers) and Hospital Long Term Care Units: (Regulated by the Kansas Department of Health and Environment)

Application Forms:

• Application and Instructions for Medical Care Facility License
• Application and Instructions for Home Health Agency License
• Statement of Attestation for Home Health Agency License

Ambulatory Surgery Center (ASC) Survey Forms:

• ASC Licensure / Risk Management Survey Report
• Statement of Deficiencies and Plan of Correction Instructions - Health
• Interviews for ASC's
• Surgical and Anesthesia Records
• ASC Entrance Checklist
• ASC Surveyors Worksheet
• Infection Control Surveyor Worksheet
• Appendix L, Interpretive Guidelines for Ambulatory Surgical Centers

Change/Complaint Forms:

• Request to Change Use of a Required Room (for KDHE regulated long term care units of hospitals)
• Request to Change Bed Capacity and/or Location (for KDHE regulated long term care units of hospitals)
• Facility Complaint Investigation Report Form (for KDHE regulated facilities)

Critical Access Hospital Survey Forms:

• Hospital Restraint/Seclusion Death Report Worksheet - Long Form
• Hospital Restraint/Seclusion Death Report Worksheet - Short Form
• Hospital/CAH Medicare Database Worksheet
• Critical Access Hospital Procedures
• CAH Entrance Conference Information Sheet
• CAH Licensure/Risk Management Survey Report
• CAH Medical Record Review Worksheet
• CAH Medical Staff Credentialing Personnel Record - Page 1
• CAH Medical Staff Credentialing Personnel Record - Page 2
• CAH Patient Interview Worksheet
• CAH Voluntary Self Review (.xls)
• CAH Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals and Swing-Beds
• Statement of Deficiencies and Plan of Correction Instructions - Health

General Hospital and Special Hospital Survey Forms:

• Guidelines for the Operation of a Freestanding Emergency Department
• Hospital Restraint/Seclusion Death Report Worksheet - Long Form
• Hospital Restraint/Seclusion Death Report Worksheet - Short Form
• Hospital-Appendix A - Survey Protocol
• Hospital/CAH Medicare Database Worksheet
• Requested Hospital and Medical Staff Documents and Reports
• Entrance Conference Information Sheet
• Licensure/Risk Management Survey Report
• Medical Record Review Worksheet
• Medical Staff Credentialing Personnel Record - Page 1
• Medical Staff Credentialing Personnel Record - Page 2
• Patient Interview Worksheet
• Statement of Deficiencies and Plan of Correction Instructions - Health

Statement of Deficiency/Plan of Correction Forms and Instructions:

• Statement of Deficiency Instructions for State Agencies
• Instruction Pamphlet
• POC Instructions for Providers & Suppliers
• Providers POC Form
• Sample POC

Risk Management Forms:

• Quarterly Report Form
• Instructions for Quarterly Report Form
• Risk Management Incident Report Form
• Risk Management Standard of Care Interpretive Guidelines
• Risk Management Mailbag
• June 2009
• October 2009
• Risk Management Regulations with Surveyor Guidance
• Sample Risk Management Plan
• Risk Management Plan Review Tool
• Risk Management Annual Reports
• 2009 - "First Do No Harm - Preventing the Avoidable"
• 2008 - "Life Happens!"
• 2007 - "Managing Medical Technology and Other Risk Management Challenges"
• 2006 - "The Triumphs and Challenges of Emergency Medicine"
• Risk Management Training Slides - Part I
• Risk Management Training Slides - Part II
• Statement of Deficiencies and Plan of Correction Instructions - Risk Management

Medicare Certification Forms:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.

• Medicare Learning Network Provider/Supplier Specific Information:

Home Health Agencies:

State Licensure/Complaint Forms:

• Application and Instructions for Home Health Agency License
• Agency Complaint Investigation Report Form (NEW)
• HHA Licensing Decision Tree
• Statement of Deficiencies and Plan of Correction Instructions - Health

Medicare Certification Forms:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.

• Medicare Learning Network Provider/Supplier Specific Information:   

OASIS Training:

• OASIS

Other Provider Types Regulated by BHF but not requiring State Licensure:

Comprehensive Outpatient Rehabilitation Facility  
End Stage Renal Disease (Dialysis) Facilities
Hospice
Outpatient Provider of Physical Therapy/Occupational Therapy/Speech Pathology Services
Portable X-ray Facility
Rural Health Clinic

Medicare Certification Forms:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.

• Medicare Learning Network Provider/Supplier Specific Information: