Adult Care Home Licensure and Certification

Licensure Information & Forms

Medicare Forms

Medicaid Enrollment Forms

FileTypeSizeUploaded onDownload
W-9 Tax ID NumberPDF74.51 KB14 Apr, 2021 Download
Instructions for Changes to be Filed with MedicaidPDF109.53 KB14 Apr, 2021 Download
Provider AgreementPDF261.24 KB14 Apr, 2021 Download
CMS 671 - Long Term Care Facility ApplicationPDF363.30 KB14 Apr, 2021 Download
National Provider Identifier Update FormPDF31.20 KB14 Apr, 2021 Download
Disclosure of Ownership and Control Interest StatementPDF269.88 KB14 Apr, 2021 Download

HCBS Provider Enrollment Information

Kansas Medical Assistance Program (KMAP)

Home and Community Based Services (HCBS) Providers can access publications, interactive tools, and other helpful information regarding enrollment here.

License Renewal and Change Forms

  • 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 an online 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.

    For any questions regarding this application, please contact KDADS SCCC Licensing at [email protected].

  • 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.

    For any questions regarding this application, please contact KDADS SCCC Licensing at [email protected].  
  • Questions regrading access to KOTA should be directed to:

    KDADS Applications Help Desk:

    Monday - Friday, 7 am - 5 pm CST
    Phone: 785-296-4987 - Option 1
    E-mail: [email protected]