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Affiliation Checklist

Please attach the following information to your Provider Application.

 

Agencies in business two (2) years or less must submit a business plan addressing the areas listed on the outline with applicable appendices, to include all items listed below. Agencies in business for more than two (2) years must submit information about the agency including how long the business has been providing services, what services are provided, what populations are served, etc. All agencies must provide the information below in their application. 

    • Organizational Chart
    • Personal financial statement demonstrating sufficient resources to keep the organization fiscally solvent during the first three years.
    • Basic set of organizational policies which must include:
      • Criminal background checks of employees. Must check at hire and have a policy or procedure to ensure staff maintain compliance with background requirements. Required to run checks with: Adult Protective Service (APS), Child Protective Service (CPS), Kansas Dept. of Health and Environment (KDHE), Kansas Bureau of Investigation (KDHE) and Dept. of Motor Vehicles (DMV) [DMV check only required if transporting consumers].
      • Dispute resolution for consumers
      • Medicaid Fraud, Waste and Abuse policy that includes training for all employees
      • Emergency/crisis backup plan which may include emergency on‐call availability

 

A written statement verifying that the person who will sign the affiliation agreement is authorized to do so. This can be in the form of a letter on company letterhead.

 

Background checks (APS, CPS, KDHE (nurse aid registry), KBI/HOC, National Sex Offender Registry and DMV) for officers of the organization and anyone handling funds. Background checks cannot be older than 2 years.

 

At least one written statement from someone requesting your service in Sedgwick County.

 

Three letters of reference regarding you or your organization. Letters may not be from relatives, employees or individuals receiving payment from you or your business.

 

If the applicant company or individual has previously held a license for a similar service within the last 10 years, a letter or other documentation demonstrating good standing from the licensing entity is required. Similar services may include but are not limited to: foster care, any type of group home or congregate care, child placing agency, etc.

 

A Tax Clearance Certificate which may be requested this online at: https://www.kdor.ks.gov/apps/taxclearance/Start.aspx There is no charge for this certificate. When asked the reason for requesting the certificate, check the Other box and indicate CDDO affiliation requirement.

 

Certificate(s) of Insurance (ACORD Form 25) in the company’s name with Sedgwick County listed as an additional insured for:

    • Worker’s Compensation ($500,000)
    • General Liability ($1,000,000 each occurrence, $2,000,000 general aggregate)
    • Auto Liability ($500,000 minimum)
    • Professional Liability ($1,000,000.00 each claim, $1,000,000.00 aggregate)

 

If you intend to provide residential services in a provider‐controlled site you will need to install water temperature control devices to prevent the water temperature from exceeding 120 degrees. QA staff from the CDDO must physically check the water temperature prior to individuals occupying the site.

 

If this is a new, startup company that does not have a history of providing IDD or Medicaid billable services additional training and orientation may be required.