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 Licensure, Certification and Evaluation Commission (LCE) of the Kansas Department on Aging (KDOA).

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 on Aging (KDOA) 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 KDOA, use the Credit Card Application form.

KDOA currently accepts:

• American Express
• Discover Card/Novus
• MasterCard
• VISA

State Licensure Forms:

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• Application and Instructions (Part I-II) for Adult Day Care License
• Application and Instructions (Part I-II) for Home Plus or Boarding Care Home License
• Application (Parts I-III) and Instructions for Adult Care Home License

Change/Complaint Forms:

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• Notice of Change of Administrator or Operator
• Request to Share Administrator/Operator
• Request to Change Use of a Required Room
• Request to Change Bed Capacity and/or Location
• Facility Complaint Investigation Report Form
• ANE Witness Form (PDF)
• ANE Witness Form (Word)

Medicaid Enrollment Forms:

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• National Provider Identifier Update Form
• Medicaid Provider Agreement
• CMS 671 LTC Application
• W-9 Tax ID Number

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

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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