Application for License 660-05-20-15
(Revised
1/1/20 ML 3572)
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An application for licensure must be made to the HCBS Case Manager in the department of Human Services.
The applicant may withdraw an application at any time during the licensing
process by notifying the Aging Services Division or the HCBS Case Manager.
An application is not complete until all required information and verifications
are submitted to the HCBS Case Manager Department of Aging Services Division. This includes:
- Evidence that all applicants
have requested qualified service provider status and the completed forms listed below have been approved by the Medical Services Division.
- SFN 1605,
“Individual Request to be a Qualified Service Provider/AFC Provider”
- SFN 750,
“Documentation of Competency,” or applicable license, certification, or
accreditation
- SFN 615, “Medicaid Program Provider Agreement”.
- SFN 1168, “Ownership Controlling Interest and Conviction Information”.
- SFN 433, “Child Abuse and Neglect Background Inquiry”.
- W 9 “Request for Taxpayer Identification Number & Certification”.
- A copy of a form of ID, ex: driver’s license or social security card.
- Evidence that all
applicants and individuals age 18 or over living in the potential facility have completed:
- SFN 467, “Personal Authorization
for Criminal Record Inquiry”
- SFN 466, “Background Check
Address Disclosure”
- Two fingerprinting cards,
if required
- A signed SFN
800, “Fire Safety Self Declaration,” form relating to fire safety
of the home
- Documentation of applicant’s
completion of a Department approved Fire Prevention
and Safety Course
- Proof of auto insurance (Section 660-05-30-40)
- A report of professional
inspection of the heating and electrical system for operability and safety (Section 660-05-30-30 (2))
- A copy of the applicant’s
home floor plan indicating escape routes (Section 660-05-30-30 (11))
- A copy of the provider’s Service and Rental Agreement including landlord tenant and eviction and appeals process, and all items listed in (Section 660-05-30-45). Service and rental agreement must be signed by the provider and the resident or resident’s legal representative.
- Examples of service logs
that will be used to account for service time and tasks performed (Section
660-05-65-95).
- Examples of daily menu
plans
- Three reference letters
(Section 660-05-65-25 for examples)
- If applicable, proof of
current pet vaccinations
- Additional information
and verifications as requested by the Department (Section 660-05-20-15-05)
- Complete a SFN 823, "Family Evacuation Disaster Plan"
(Section 05-65-90)
