For hospice agency licensing, submit the following:
- Copy of In-home Services Orientation Class “certificate of completion.” Applications will not be processed unless a certificate of completion has been submitted.
- Completed in-home services application (PDF), along with the initial licensing fee.
- Proof of current commercial general liability insurance according to WAC 246-335-320(2)(b).
- Disclosure statements for the on-site administrator and director of clinical services according to WAC 246-335-320(2)(d) dated within three months of the application date.
- Criminal history background checks processed through the Washington State Patrol for the on-site administrator and director of clinical services according to WAC 246-335-320(2)(d) dated within three months of the application date.
- Copy of any and all current government-issued business licenses for each office location; this may include state, county, or city licenses.
- Completed full-time equivalent worksheet.
- A description of the agency's organizational structure listing; for example, the names of the officers, administrator, director of clinical services, and other key positions.
- A description of how the agency will provide management and supervision of hospice services throughout all requested service areas.
- A description of the services the agency will offer directly and those offered under contract.
Submit all of the above to the address shown in the application packet above.
After review and acceptance of the application materials, the department's Office of Investigation and Inspection will contact the applicant and schedule an initial survey. Applicants must pass the survey process in order for their license to be issued.
Important notice: According to WAC 246-335-320(4), the department may close out an application, with no refund of licensing fees being issued, if an applicant has not completed all steps required for licensure within nine months.
Federal Medicare-certified Hospice Agency Application
Note: State licensure as a hospice agency is a requirement for federal certification. For state-licensed hospice agencies interested in Medicare certification, complete the following steps:
- Review the following Medicare regulations for hospice agencies:
Federal Medicare Regulations: Hospice
Regulations: 42 CFR 418.50 Part C
Regulations: 42 CFR 418.80 Part D
Regulations: 42 CFR 418.90 Part E
State Operations Manual: Hospice
Regulations: SOM 2080-2089
- Contact the department's Certificate of Need program at 360-236-2955 before applying for Medicare certification.
- Once Certificate of Need approval is granted, submit the Medicare application form 855A to the CMS Fiscal Intermediary (FI).
- The FI will review form 855A and, if approved, will send a copy of the approval to the Medicare Program in the Office of Investigation and Inspection.
- The Medicare Program in the Office of Investigation and Inspection will contact the applicant and request specific Medicare-related forms to be completed.
- Submit the completed forms to the Medicare Program in the Office of Investigation and Inspection.
- After review and acceptance of the application materials, the department's Office of Investigation and Inspection survey team conducts an on-site survey before recommending the hospice agency for Medicare certification.