State ACH Licensure Forms

Criminal Record Check Program

Effective July 1, 2018, Senate Substitute for House Bill 2386 (originally HB 2427) passed this legislative session and became effective 7/1/2018. The bill made changes to the criminal record check laws for Adult Care Homes (K.S.A. 39-970), Home Health Agencies (K.S.A. 65-5117) and HCBS (K.S.A. 39-2009).

Prohibited Offense List

Effective July 1, 2018, the New Prohibited Offense List is now identical for Adult Care Homes, Home Health Agencies, and HCBS Providers. There are some new offenses while some previously prohibited offenses have been removed. The revised list is posted on the Health Occupations Credentialing website.

  • National Finger-Print Based Criminal Record Checks will be implemented in phases. There will be no fee increase until the finger-print based checks are implemented.
  • This new background check system, called KanCheck, will be implemented in phases.

Forms

These pages provide downloadable PDFs for state licensure, and related forms, and instructions for health care providers regulated by the Health Facilities Program. Additionally, the pages provide links to Medicare certification forms and related information which may be applicable to health care providers seeking Medicare reimbursement:

Visit the Centers for Medicare and Medicaid Services website (formerly Health Care Financing Administration) to find specific provider/supplier enrollment forms; associated information can be found on these pages.

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 for KDHE regulated providers can be directed to the Hospital and Medical Program at 785-296-0127.

Fee Payment

Submission of the Home Health Agency application state licensure form below also requires a fee. KDHE currently accepts only checks or money orders for these fees made payable to Health Facilities Program or KDHE.