Medical Services Division Responsibilities 660-05-25-20
(Revised 1/1/20 ML 3572)
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- Review the qualified service
provider (QSP) application for all adult foster care applicants/providers,
respite care providers and substitute caregivers which includes:
- 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.
- Return application forms
if not complete. Notify the HCBS Case Manager and Aging Services Division of status
of QSP application.
- Review background check
forms for completion and forward to Aging Services Division to complete the check for adult
foster care applicants/providers, relatives in the home, substitute
caregivers, and respite care providers which includes:
- SFN 467, “Personal Authorization
for Criminal Record Inquiry”
- SFN 466, “Background Check
Address Disclosure”
- Two fingerprint cards,
if required
- Determine expiration date
of adult foster care license based on background check results
and expiration of QSP status. Notify the HCBS Case Manager and Aging Services Division responsible for licensing of the expiration date.
- For license renewal, notify
the provider, the HCBS Case Manager and the Aging Services Division in writing 90 days prior to the expiration date.
- Refer all complaints and investigation findings to Aging Services Division.
- If revocation of a license is warranted, the Aging Services Division will issue a revocation letter (Section 660-05-45) to the provider. Upon request, assist the provider in the completion of SFN 747,” Adult Foster Care Appeal Form.” Send copies of the forms to the Aging Services Division and the HCBS Case Manager.
