AP-2204 REV. 09/08/2014
LICENSE APPLICATION
Day Services
Residential
(K.A.R. 30-63-10 et.seq)
COMMUNITY SERVICE PROVIDER
New Application
Renewal Application
Supplement to Application
[1] I/DD Service Provider (Legal Name)
[3] Federal ID Number/EIN
[2] Agency Mailing Address
City
State
Zip
[4] Requested Effective Start Date
Submit application at least
KS
60 days before start date
[5] Director/Administrator/CEO/President
[6] Phone Number
[9] Principal Affiliating CDDO
primary service area
(
)
-
[7]
[8] Fax Number
[10] Other Affiliating CDDO
Email Address/Agency Web Address (if applicable)
additional service area
(
)
-
[11] Board Chair
[12]Mailing Address
[13]Phone Number [14]Fax Number
(if applicable)
(
)
-
(
)
-
[15] Location(s) where services will be provided
(List all physical locations, phone numbers, and capacity to serve* add additional pages, if needed)
Physical Address
Phone Number
Capacity to Serve
(
)
-
Physical Address
Phone Number
Capacity to Serve
(
)
-
Physical Address
Phone Number
Capacity to Serve
(
)
-
CERTIFICATIONS
1.
I agree to abide by all laws, KMAP provider requirements, regulations, training materials, policies and procedures governing the
provision of community services for people with developmental disabilities including the HCBS I/DD Waiver.
2.
I agree to fully cooperate with and be responsive to requests from and service reviews by the Kansas Department for Aging and Disability
Services (KDADS) or its agents, and/or any CDDO in whose area community services are provided.
3.
I understand that after notice and an opportunity to correct the deficiencies, the license status can be negatively affected, up to and including
revocation of the license.
4.
I certify that the licensee has and will maintain all licenses, certificates, and inspections of all local, county, state, and federal authorities,
and that all wage and hour protections are in place under the FLSA. [e.g. Minimum wage payments, withholding taxes, occupational and
health safety, zoning, fire safety inspections] .
5.
I certify that services provided under this license will only be provided by employees of the licensee and that no person will be served in a
location without such location having first been inspected and approved by local, county, state, and federal authorities, including KDADS.
6.
I certify that the information provided above is true, full, and complete to the best of my knowledge, information, and belief. I further
certify that I will supplement this application to KDADS within seven days if any of the information changes, including but not limited to
the addition of a location(s).
AUTHORIZATION
AS AN AUTHORIZED AGENT OF APPLICANT, I HAVE READ THE LAWS AND REGULATIONS GOVERNING THE
OPERATION OF A COMMUNITY SERVICE PROVIDER. APPLICANT, IF GRANTED A LICENSE, WILL COMPLY AND
COOPERATE WITH KDADS AND WILL BE RESPONSIVE TO ITS REQUESTS. APPLICANT WILL MAINTAIN CURRENT
INFORMATION ON THIS APPLICATION, AND ANY ATTACHMENTS, AND WILL NOTIFY KDADS AND SUPPLEMENT
THIS APPLICATION IF ANY INFORMATION CHANGES.
Signature
Title
Date
Send Applications to: KDADS Community Services and Programs
Website:
ATTN: Quality Assurance/Licensing
Phone: 785-296-4740
503 S. Kansas Ave Topeka
Fax: 785-296-0256
Topeka, Kansas 66603
Email:
HCBS-KS@kdads.ks.gov
Internal Use Only
QA Recommend?
Y
N
Date ____________
CDDO Affiliation
Y
N
Date ____________
I certify that I completed the following tasks: Name___________________________ Signature ______________________________ Date _____________