AGING AND DISABILITY SERVICES ADMINISTRATION
2005 AFH "Dear Provider" Letters
September 9, 2005
ADSA: AFH #2005-014
Revised Background Authorization Form & Account Numbers
Dear Adult Family Home Provider
The Department of Social and Health Services (DSHS), Background Check Central
Unit (BCCU) has revised the Background Authorization form you are currently using (DSHS 09-828) to enable all providers to use a single, standardized form to request background checks on staff.
Effective October 1, 2005, you may begin using the revised form (DSHS 09-653). A sample of this form with instructions is enclosed for your reference. The revised form will be accessible online at http://www1.dshs.wa.gov/msa/forms/eforms.html as the implementation date approaches. A link to the revised form will also be provided on the ADSA website, AFH Professional Page, at http://www.aasa.dshs.wa.gov/Professional/afh.htm.
Each entity required to conduct background checks through the BCCU has an assigned BCCU account number. Your account number is the same as your AFH license number. On the revised Background Authorization:
- Section 1, Item 1 (Name of Entity Requesting Background Check) - List the name of your facility as it appears on your AFH license.
- Section 1, item 4 (BCCU Account Number) - List your AFH license number.
Additional information about BCCU account numbers can be accessed on the BCCU web page at http://www1.dshs.wa.gov/msa/bccu/BCCU-account.htm.
When requesting a criminal history background check on a staff person, you must send your request using the revised DSHS Form 09-653 to the BCCU by mail or fax as follows:
Background Check Central Unit
PO Box 45025
Olympia, WA 98504-5025
FAX: (360) 902-0292
Effective November 1, 2005, use of the revised form becomes mandatory; requests that are submitted on any form other than DSHS 09-653 will be rejected.
Please contact your RCS Field Manager if you have questions regarding the use of the revised form.
Sincerely,
Joyce Pashley Stockwell, Director
Residential Care Services
