In Home Services License Application Packet 505052

User Manual: 505052

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DOH 505-052 March 2013
In-Home Services License Application Packet
Contents:
1. 505-052 ....Contents List / Mailing Information ................................................ 1 Page
2. 505-053 ....Application Instructions Checklist ................................................ 3 Pages
3. 505-109 ....License Requirements...................................................................1 Page
4. 505-051 ....In-Home Services Application ..................................................... 5 Pages
5. 505-055 ....Disclosure Statement ....................................................................1 Page
6. RCW/WAC and Online Web Site Links ...........................................................1 Page
In order to process your request:
Mail your application with initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health In-Home Service Credentialing
PO Box 1099 PO Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
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DOH 505-053 March 2013 Page 1 of 3
When your application for In-Home Services Agency License is received by the
Department of Health (DOH), it will be reviewed and you will be notied in writing of any
outstanding documentation needed to complete the process.
All information should be typed or printed clearly in blue or black ink. It is your
responsibility to submit the correct required forms.
Indicate type of application—new, change of ownership, amended or renewal.
• New—First time requesting an In-Home Service Agency license.
• Change of Ownership—When name of legal owner/operator changes resulting
from the sale of a licensed In-Home Service Agency.
• Amended—To request the addition of a Service Category (e.g. Home Care,
Hospice, Hospice Care Center, Home Health); add or eliminate Service(s),
change Accreditation information, add or eliminate a Service Area(s), change
Administrator, Clinical Director or Direct Supervisor information, add Other
Ofce Locations.
• Renewal—To renew an existing In-Home Services License.
FCheck One: Please check your legal owner/operator business structure type
according to your Washington State Master Business License.
FApplication Fee: You can check the online fee page for current fees.
F1. Demographic Information:
UniformBusinessIdentierNumber(UBI#):Enter your Washington State UBI
#. All Washington State businesses must have UBI #s. City, county, and state
government departments also have UBI #s.
 FederalIDNumber(FEIN#):Enter your Federal ID Number, if the business has
been issued one.
Legal Owner/Operator Name: Enter the owner’s name as it appears on the
UBI/Master Business License.
Mailing Address: Enter the owner’s complete mailing address.
Phone and Fax: Enter the owner’s phone and fax numbers.
 EmailandWebAddress: Enter the owner’s email and facility Web addresses, if
applicable.
Facility/Agency Name: Enter the doing business as name. Name used on
advertising, signs, and web sites.
Physical Address: Enter the facility’s physical street location including city, state,
zip code, and county.
Phone and Fax Numbers: Enter the agency’s phone and fax number.
Mailing Address: Enter the agency’s mailing address, if different than physical
address.
Application Instructions Checklist
F2.FacilitySpecicInformation:
A. Service Categories: Please check all in-home service categories that
apply.
Service Categories of Home Care, Home Health, and Hospice: Enter the
number of Full Time Equivalents (FTEs). To calculate FTEs, an example would
be, take your agency’s total labor hours for one year and divide that number by
2080.
Service Categories of Hospice Care Center: Enter the number of licensed
beds authorized by the Certicate of Need and Construction Review Services.
B. Services Provided:
Home Care Services: Please check all that apply.
Home Health Services: Please check all that apply. You must choose at least
two home health services before you may provide home care services.
Hospice Services: Please check all that apply.
Hospice Care Center Services: Please check all that apply.
C. MedicareDesignation/Certication:
Please check if agency is Medicare certied to provide Home Health or
Hospice services. If check Yes, enter the corresponding six character provider
number(s). In Washington this provider number always begins with 50. If you
do not know your six character provider number, please contact your Medicare
Fiscal Intermediary.
AAA and/or DDD Contracts:
Check yes or no. If yes, please enter the contract dates, last monitoring survey
and the agency who conducted the monitoring survey.
Accreditation Information:
Agency 1 and 2: If your agency is accredited, please enter the name of the
accreditation agency, the accreditation effective date, expiration date, and
check the box for accreditation as a Home Health or Hospice agency.
D. Service Areas:
Check the service counties and service categories in which you deliver care to
patients or clients. If you only deliver care in part of a county, attach a separate
sheet describing the service area within the county. For Medicare, check both
state counties you provide services in as well as those counties that were
authorized by Certicate of Need for Medicare.
F3. Key Individuals:
A. Administrator:
Enter the administrators name, phone number, fax number, email address, and
hire date. This must be the same person identied on the Disclosure Statement
and Criminal History Background Check.
 DirectSupervisor(HomeCareCategory):Enter the supervisor’s name,
phone number, fax number, email address, and hire date. This must be the
same person identied on the Disclosure Statement and Criminal History
Background Check.
DOH 505-053 March 2013 Page 2 of 3
 ClinicalDirector(HomeHealthand/orHospiceCategory): Enter the
director’s name, phone number, fax number, email address, and hire date. This
must be the same person identied on the Disclosure Statement and Criminal
History Background Check.
B. Legal Owner Information:
List the names, titles, addresses, and phone numbers of the corporate ofcers,
LLC members, partners, individuals owning 10% or more of the agency. Attach
additional sheet, if necessary.
F4.OtherOfceLocations:
OtherOfceLocations:
Enter the name, street address, mailing address, phone number, fax number, email
address, and on-site manager or supervisor name. Check the service categories
provided from this location. If there are more than two locations, please attach
additional sheets as needed. If this is an approved Medicare Branch Ofce, check
the box.
F5. Change of Ownership Information:
For the current and prospective legal owners, enter the name, phone number,
current license number, agency name, agency address, email address, and
effective date of ownership change. Current and prospective legal owners must
attest to the change in ownership by signing their names on the space provided
and indicate the date signed.
FSignature:
Signature of legal owner or authorized representative.
Date signed.
Print name of legal owner or authorized representative.
Print title of legal owner or authorized representative.
Additional Information:
For more information on serving state funded DSHS clients, please contact your local
Area Agency on Aging (AAA) at 1800-422-3263 or the Division of Developmental
Disabilities (DDD) at 1800-562-3022.
DSHS can explain the requirements for contracting with them. Contracts are not
available to newly licensed home health agencies.
Contact the AAA or DDD before completing the Department of Health application packet
if you wish to also provide services to DSHS clients.
The Area Agency on Aging can be found at http://www.aasa.dshs.wa.gov/.
DOH 505-053 March 2013 Page 3 of 3
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License Requirements
In order to process your request you must provide the
following:
FReturn completed application, along with the application fee.
FProfessional and Liability Insurance: Attach proof of the current professional and
liability insurance as per WAC246-335-025.
FDisclosure Statement : Attach a copy of the Disclosure Statement for the on-site
Administrator/Director, Director of Clinical Services (Home Health or Hospice), or
Supervisor of Direct Care Services (Home Care). Agencies must keep on le a
current Disclosure Statement for the Administrator, Director of Clinical Services
or Supervisor of Direct Care Services as stated in WAC246-335-025(1)(c) and
WAC246-335-030(3). Current copies must be dated within 3 months of the initial
application date.
FCriminal History Background Check (CBC): Attach a copy of the current CBC of
the on-site Administrator, Director of Clinical Services (Home Health or Hospice),
or Supervisor of Direct Care Services (Home Care). Agencies must keep on le
a current CBC for the Administrator, Director of Clinical Services or Supervisor of
Direct Care Services as stated in WAC246-335-025(1)(c) and
WAC246-335-030(3). Current copies must be dated within 3 months of the initial
application date.
FCopy of any and all current government issued business license(s) for each ofce
location which may include state, county or city licenses.
FA description of how the agency will provide management and supervision of
services throughout the service area(s).
DOH 505-109 March 2013
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DOH 505-051 March 2013 Page 1 of 6
Revenue:0597632360
1. Demographic Information
UBI # Federal Tax ID (FEIN) #
Legal Owner/Operator Name
Phone (enter 10 digit #) Fax (enter 10 digit #)
Mailing Address
City State Zip Code County
Facility / Agency Name (Doing business as name. Name used on advertising, signs, and web sites)
Facility Phone (enter 10 digit #) Facility Fax (enter 10 digit #)
City State Zip Code County
Physical Address
City State Zip Code County
Mailing Address (If different than physical address)
Email Address Web Address:
Date
Stamp
Here
License #___________________________________________ Issue Date ___________________________
ForOfceUseOnly
In-Home Services Agency License Application
This is for: F New F Change of Ownership F Amended F Renewal
Check One
F Limited Partnership
F Municipality (City)
F Municipality (County)
F Non-Prot Corporation
F Partnership
F Association
F Corporation
F Federal Government Agency
F For-Prot
F Limited Liability Company
F Limited Liability Partnership
F Public Hospital District
F Sole Proprietor
F State Government Agency
F Tribal Government Agency
F Trust
2. Facility Specic Information
A. Check all service categories provided:
B. Check all services provided:
Home Health Services - Choose a least two services provided
ServiceCategory#ofFTE’s ServiceCategory#ofBeds
F Home Care _____ F Hospice Care Center ______
F Home Health _____
F Hospice _____
F Skilled Nursing F Respiratory Therapy F Bereavement Counseling
F Home Health Aide F Medical Social Services F Physical Therapy
F Durable Medical Equipment F Occupational Therapy F I.V. Services
F Speech Therapy F Nutritional Counseling F Applied Behavior Analysis
In addition to those services listed above, you may select any of the following:
F Personal Care F Respite Care F Transportation
F Homemaker/Chore
Home Care Services
F Personal Care F Respite Care F Transportation
F Homemaker/Chore
Hospice Care Center Services
F Continuous Care F Routine Home Care F General In-Patient Care
F In-Patient Respite Care
DOH 505-051 March 2013 Page 2 of 6
Is agency currently Medicare certied? F Yes F No
Home Health Medicare Provider # ____________________ Hospice Medicare Provider #_____________________
Does the agency have a DSHS Medicaid contract? F Yes F No Secure Fax (enter 10 digit #) ________________
If yes, complete all the below AAA and/or DDD contracts that apply:
ContractDates LastMonitoringSurvey ByWhom
F DSHS Personal Care Program ______to______ ____________________ ________________
F DSHS Chore Services ______to______ ____________________ ________________
F DSHS Respite Program ______to______ ____________________ ________________
F DSHS / DDD ______to______ ____________________ ________________
F Other ______to______ ____________________ ________________
C. Medicare, Medicaid, and Accreditation information:
Hospice Services
F Skilled Nursing F Durable Medical Equipment F Respite Care
F Home Health Aide F I.V. Services F Volunteer
F Physical Therapy F Nutritional Counseling F Spiritual Counseling
F Occupational Therapy F Bereavement Counseling F Pallative Care
F Speech Therapy F Personal Care F Symptom & Pain Mgmt.
F Respiratory Therapy F Homemaker/Chore F Pharmacy Services
F Medical Social Services
Name of Accreditation Agency #1
_________________________________
Effective Date______________________
Expiration Date_____________________
Name of Accreditation Agency #2
_________________________________
Effective Date______________________
Expiration Date_____________________
F Home Health F Hospice F Home Health F Hospice
F Adams F F F F F F F
F Asotin F F F F F F F
F Benton F F F F F F F
F Chelan F F F F F F F
F Clallam F F F F F F F
F Clark F F F F F F F
F Columbia F F F F F F F
F Cowlitz F F F F F F F
F Douglas F F F F F F F
F Ferry F F F F F F F
F Franklin F F F F F F F
F Gareld F F F F F F F
F Grant F F F F F F F
F Grays Harbor F F F F F F F
F Island F F F F F F F
F Jefferson F F F F F F F
F King F F F F F F F
F Kitsap F F F F F F F
F Kittitas F F F F F F F
F Klickitat F F F F F F F
F Lewis F F F F F F F
F Lincoln F F F F F F F
F Mason F F F F F F F
F Okanogan F F F F F F F
F Pacic F F F F F F F
F Pend Oreille F F F F F F F
F Pierce F F F F F F F
F SanJuan F F F F F F F
F Skagit F F F F F F F
F Skamania F F F F F F F
F Snohomish F F F F F F F
F Spokane F F F F F F F
F Stevens F F F F F F F
F Thurston F F F F F F F
F Wahkiakum F F F F F F F
F Walla Walla F F F F F F F
F Whatcom F F F F F F F
F Whitman F F F F F F F
F Yakima F F F F F F F
D. Requested Service Areas
DOH 505-051 March 2013 Page 3 of 6
Home
Care
State Home
Health
State
Hospice
State Hospice
Care Center
Medicare
Home
Health
Medicare
Hospice
Medicare
Hospice
Care Center
County
3. Key Individuals
Administrator Name
Phone (enter 10 digit #) Fax (enter 10 digit #)
Email Address Hire Date
Direct Supervisor Name (Home Care)
Clinical Director Name (Home Health, Hospice)
DOH 505-051 March 2013 Page 4 of 6
A. Complete all that apply:
Phone (enter 10 digit #) Fax (enter 10 digit #)
Email Address Hire Date
Email Address Hire Date
Phone (enter 10 digit #) Fax (enter 10 digit #)
B. Legal Owner Information–attach additional sheets as needed
List the names, titles, addresses, and phone numbers of the corporate ofcers, LLC members, partners, individuals
owning 10% or more of the agency.
Name Title
Mailing Address
City State Zip Code Phone (enter 10 digit #)
Name Title
Mailing Address
City State Zip Code Phone (enter 10 digit #)
Name Title
Mailing Address
City State Zip Code Phone (enter 10 digit #)
DOH 505-051 March 2013 Page 5 of 6
Ofce Name F Approved Medicare Branch Ofce
On-Site Manager or Supervisor
Physical Address
City Zip Code County
Mailing Address (if different from physical)
Email Address
In-Home services categories provided from this location
F Home Health F Home Care F Hospice F Hospice Care Center
Phone (enter 10 digit #) Fax (enter 10 digit #)
Ofce Name F Approved Medicare Branch Ofce
On-Site Manager or Supervisor
Physical Address
City Zip Code County
Mailing Address (if different from physical)
Email Address
In-Home services categories provided from this location
4. Other Ofce Locations - Attach additional completed pages if you need more space.
F Home Health F Home Care F Hospice F Hospice Care Center
Phone (enter 10 digit #) Fax (enter 10 digit #)
Ofce Name F Approved Medicare Branch Ofce
On-Site Manager or Supervisor
Physical Address
City Zip Code County
Mailing Address (if different from physical)
Email Address
In-Home services categories provided from this location
F Home Health F Home Care F Hospice F Hospice Care Center
Phone (enter 10 digit #) Fax (enter 10 digit #)
Signature
I certify that I have received, read, understood, and agree to comply with state law and rule regulating this licensing
category. I also certify that the information herein submitted is true to the best of my knowledge and belief.
___________________________________________________________ _____________________________________
Signature of owner/authorized representative Date
___________________________________________________________ _____________________________________
Print Name Print Title
Name of Current Legal Owner:
Name of Current Facility/Agency:
Current Facility/Agency Physical Address:
5. Change of Ownership Information
Name of Prospective Legal Owner: Prospective Owner Phone (enter 10 digit #):
Name of Prospective Facility/Agency: Prospective Owner Email Address:
Prospective Facility/Agency Physical Address:
_______________________________________________ ____________________________________________
_______________________________________________ ____________________________________________
Signature of current legal owner Date Signature of prospective legal owner Date
Print name of current legal owner Date Print name of prospective legal owner Date
DOH 505-051 March 2013 Page 6 of 6
Effective Date of Ownership Change: Current Owner Phone (enter 10 digit #):
Current Facility/Agency License Number:
Disclosure Statement
I, ________________________________________________________________ have never been:
1. Convicted of a crime against children or other persons.
Aggravated murder; rst or second degree murder; rst or second degree kidnapping; rst,
second, third degree assault; rst, second, or third degree assault of a child; rst, second, or third
degree rape; rst, second, or third degree rape of a child; rst or second degree robbery; rst
degree arson; rst degree burglary; rst or second degree manslaughter; rst or second degree
extortion; indecent liberties; incest; vehicular homicide; rst degree promotion prostitution;
communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of
minors; rst or second degree criminal mistreatment; child abuse or neglect as dened in
RCW26.44.020; rst or second degree custodial interference; malicious harassment; rst,
second, or third degree child molestation; rst or second degree sexual misconduct with a
minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or
distributing erotic material to a minor; custodial assault; violation of child abuse restraining order;
child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of
these crimes as they be rename in the future.
2. Convictedofcrimesrelatingtonancialexploitationifthevictimwasavulnerableadult.
A conviction for rst, second, or third degree extortion; rst, second, or third degree theft; rst
or second degree robbery; forgery; or any of these crimes that may be renamed in the future.
A vulnerable adult is an adult who lacks the functional, mental, or physical ability to care for
themselves
3. Convicted of crimes related to drugs;
A conviction of a crime to manufacture, deliver, or possession with intent to manufacture or
deliver a controlled substance.
4. Found in any dependency action under RCW13.34.040 to have sexually assaulted or
exploited any minor or to have physically abused any minor;
5. FoundbyacourtinadomesticrelationsproceedingunderTitle26RCWtohavesexually
abused or exploited any minor or to have physically abused any minor;
6. Foundinanydisciplinaryboardnaldecisiontohavesexuallyorphysicallyabuseor
exploitedanyminorordevelopmentallydisabledpersonortohaveabusedornancially
exploited any vulnerable adult;
Any nal decision issued by a disciplining authority under RCW18.130 or the secretary of the
department of health for the following businesses or professions: chiropractic, dentistry, dental
hygiene, massage, midwifery, naturopathy, osteopathic medicine and surgery, physical therapy,
physicians, practical nursing, registered nursing, and psychology.
7. Found by a court in a protection proceeding under RCW.74.34, to have abused or
nanciallyexploitedavulnerableadult.
The illegal or improper use of a vulnerable adult or that adult’s resources for another person’s
prot or advantage.
Employee Signature __________________________________________ Date: ________________
Witness Signature ____________________________________________ Date: ________________
DOH 505-055 March 2013
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RCW/WAC Links
In-Home Services Laws............................................................................... RCW70.127
In-Home Services Rules ............................................................................ WAC246-335
On-Line
In-Home Services Program .............................................................................WebPage
RCW/WAC and Online Web Site Links
RCW/WAC and Online Web Site Links March 2013

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