AGING AND DISABILITY SERVICES ADMINISTRATION
2008 AFH "Dear Provider" Letters
December 15, 2008
ADSA: AFH #2008-025
REVISED APPLICATION FOR ADULT FAMILY HOME LICENSE
Dear Adult Family Home Provider:
In response to feedback from providers and stakeholders, the department has revised the adult family home license application.
The revised application:
- Is more user-friendly.
- Adds required items that were separate additional attachments to the prior application.
- Adds a checklist to ensure that the application contains all of the required information and attachments.
- Is now available online at http://www.adsa.dshs.wa.gov/professional/afh.htm under “Applications”, and includes responses to frequently asked questions.
- Will be distributed to prospective license applicants during the adult family home orientation.
- Is designed so that the applicant can electronically complete the application and then print it out to send to ADSA.
- Is to be used by:
- Currently licensed adult family home providers who are:
- applying for an additional (e.g., a second, third, etc.) adult family home license,
- changing the license status of their currently licensed adult family home (for example, changing from a sole proprietorship to a corporation), or relocating their adult family home to a home that is not a currently licensed adult family home. (See provider letter ADSA: AFH #2008-014.)
- Applicants who are applying to be the provider for an adult family home that is not currently licensed.
You must:
- Use the revised adult family home license application form DSHS 10-410 (12/2008) beginning January 15, 2009 if you are:
- opening another adult family home,
- applying to change the license status of your currently licensed adult family home (for example, changing from a sole proprietorship to a corporation, or if spouse co-providers divorce), or
- relocating your currently licensed home.
You may:
- Begin using the revised form immediately, if needed.
- Download the revised form at http://www.aasa.dshs.wa.gov/professional/afh.htm.
- Complete the form electronically; however, you must print out the completed form, sign it, and mail it, along with the required attachments, to ADSA as specified in the application instructions.
- Call the Business Analysis and Applications Unit at (360) 725-2420 if you do not have Internet access and you need a blank adult family home application.
Note: An applicant or any person who has not held an adult family home license within the past twelve months must attend a department approved orientation class prior to submitting their application for licensure. Although the adult family home license application form will be available online and will be distributed during AFH orientation, the applicant must submit a copy of their adult family home orientation certificate (along with the adult family home application and required attachments) in order for the application to be processed.
Effective January 15, 2009, the following forms will be removed from the DSHS forms site and will no longer be accepted by the department because they have been incorporated into the revised license application:
- DSHS 10-404 - Adult Family Home Initial Attestation
- DSHS 10-401 - Change of Ownership Attestation
If you have any questions, please contact the Business Analysis and Applications Unit at (360) 725-2420.
Sincerely,
Joyce Pashley Stockwell, Director
Residential Care Services
