State Adult Care Homes Licensure Forms
This page makes available for direct download state licensure and related forms and instructions for health care providers regulated by the Survey and Certification Commission (SCC) of the Kansas Department for Aging and Disability Services (KDADS).
Additionally, this page provides links to Medicaid enrollment and Medicare certification forms and related information which may be applicable to health care providers seeking reimbursement from those programs.
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 can be directed to: Licensure and Certification Program at 785-296-1260.
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 for Aging and Disability Services (KDADS) for adult care homes (including assisted living/residential health care facilities, boarding care homes, home plus facilities and adult day care).
No fees are currently associated with payment by credit card. To make credit card payments to KDADS, use the Credit Card Application form.
KDADS currently accepts:
- MasterCard
- VISA
State Licensure Information Packet:
State Licensure Renewal:
The submission of the annual Licensure Renewal and license fees associated with the renewal is done on the Facility Home Page within a On-Line Kansas Tracking of Adult Care Homes (KOTA) Web Application. An electronic notice is sent to the Administrator prior to the renewal due date. To access KOTA, click here or on the Web Applications link on the Home Page of this website.
For any questions reguarding access to this application, please contact the KDADS Computer Help Desk at 785-296-4987.
Change Forms:
The submission of the below changes are done on the Facility Home Page within a On-Line Kansas Tracking of Adult Care Homes (KOTA) Web Application. To access KOTA, click here or on the Web Applications link on the Home Page of this website.
For any questions reguarding access to this application, please contact the KDADS Computer Help Desk at 785-296-4987.
- Change of Administrator or Operator
- Change of Facility Name / Address / Phone / E-Mail or Webpage
- Request to Share Administrator or Operator
- Request to Change Use of a Required Room
- Request for Change in Resident Capacity and/or Location
Additional Instructions for Changes to be filled with Medicare.
Adobe Reader ® software is required to view these documents.
- KDADS Requirements for Medicare Providers Change of Ownership
- KDADS Requirements for Application for Medicare Certification - Skilled Nuring Facility
Medicaid Enrollment Forms:
Adobe
Reader ® software is required to view these
documents.
- National Provider Identifier Update Form
- Medicaid Provider Agreement
- CMS 671 LTC Application
- W-9 Tax ID Number
- KDADS Requirements for Medicare Providers Change of Ownership
- KDADS Requirements for Application for Medicare Certification - Skilled Nuring Facility
Medicare Certification Forms:
Use the following links to obtain information about Medicare fee-for-service provider/supplier enrollment. Please note that Medicare reimbursement is not currently available for adult day care, home plus, and boarding care home providers.
- Medicare Fee-For-Service Provider/Supplier Enrollment
- Medicare Learning Network Provider/Supplier Specific Information
- Centers For Medicare & Medicaid Services (formerly Health Care Financing Administration) General Forms
Medical Care Facilities:
The following facilities are regulated by the Kansas Department of Health and Environment. Information regarding these facilities can be found on the KDHE web site http://www.kdheks.gov/bhfr/state_ach_licensure_forms.html
- Hospitals
- Ambulatory Surgical Centers
- Hospital Long Term Care Units
- Home Health Agencies
- Comprehensive Outpatient Rehabilitation Facility
- End Stage Renal Disease (Dialysis) Facilities
- Hospice
- Outpatient Provider of Occupational Therapy Services
- Outpatient Provider of Physical Therapy Services
- Outpatient Provider of Speech Pathology Services
- Portable X-ray Facility
- Rural Health Clinic