During the application process, we communicate with applicants by email. Please make sure you check your spam or junk folder to avoid missing important messages.
Notice for Change of Ownership (CHOW) Applicants: In order for licensees to remain in compliance with federal and state regulations (42 CFR 489.18 and WAC 388-97-4280), the applicant must complete the state CHOW application process prior to transferring ownership of the nursing home business enterprise to another party. The effective date of the CHOW for State Licensing and Medicare/Medicaid purposes will be the Bill of Sale date or the Transfer of Operations Agreement date (whichever applies).
To ensure that the flow of communication with the applicant(s) is as accurate as possible, when Business Analysis and Applications Unit (BAAU) is processing licensing and certification applications for Assisted Living Facility, Nursing Home Facility, Enhanced Services Facility and Certified Community Residential Services and Support and a third party is involved, at least one individual who is part of the applying entity must be included in all emails and/or phone calls between the third party and BAAU. This is to ensure that applicant(s) directly provide BAAU staff with accurate information; can dialogue and discuss questions about their application. We want to ensure that the flow of communication with the applicant(s) be as accurate as possible and to keep the applicant(s) informed during the application process.
In accordance with WAC 388-96-809, for ownership changes, the assigning or terminating contractor shall provide security for estimated overpayment liability. To get the assumption of liability form, or if you have any questions, please contact the Nursing Facilities Rates Payment Coordinator (DSHS) at NFRPaymentCoord@dshs.wa.gov.
APPLICATION PACKETS
Effective immediately, the street address for submissions to be delivered via Federal Express or United Parcel Service is:
4500 10th Ave SE
Lacey, WA 98503
Nursing Home Facility License Application (DSHS 10-670)
Notice for Change of Ownership (CHOW) Applicants: In order for licensees to remain in compliance with federal and state regulations (42 CFR 489.18 and WAC 388-97-4280), the applicant must complete the state CHOW application process prior to transferring ownership of the nursing home business enterprise to another party. The effective date of the CHOW for State Licensing and Medicare/Medicaid purposes will be the Bill of Sale date or the Transfer of Operations Agreement date (whichever applies).
Office for Civil Rights (OCR)
- U.S .Department Of Health & Human Services Office For Civil Rights
- OCR Clearance Package for Medicare Provider Applicants
Related Materials
Download the following individual forms or informational handouts by clicking on the corresponding link:
- Background Authorization (2 pages)
- Lease or Operating Agreement Attestation (4 pages)
- Management Agreement Attestation (4 pages)
- Form CMS-1561 (07/01) – Health Insurance Benefit Agreement (1 page)
- Form CMS 671 (12/02) – Long-Term Care Facility Application for Medicare & Medicaid (6 pages)
- Resource Information for Licensed Nursing Home Providers (3 pages)
- RCS Contacts
If you are unable to view these documents online or require materials in hard copy format, please contact the Residential Care Services Business Analysis and Applications Unit at (360) 725-2420.
If you have difficulty printing these documents, please read the Print Troubleshooting Guide.