For hospice care center licensing, submit the following:
Submit the completed in-home services application (PDF), the appropriate licensing fee and the following documentation:
- 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, which may include state, county, or city licenses.
- Completed full-time equivalent worksheet.
- A description of the agency and center'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 and center will provide management and supervision of hospice services throughout all requested service areas.
- A description of the services the agency and center 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 on-site survey. Applicants must pass the survey process in order for their license to be issued.
Federal Medicare-certified Hospice Care Center Application
Note: State licensure and federal Medicare certification as a hospice care center is required. For hospice care centers interested in Medicare certification, complete the following steps:
- Review the following Medicare regulations for hospice care centers:
Federal Medicare Regulations: Hospice Care Center
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 Care Center
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 fiscal intermediary 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 Investigations and Inspections.
- 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 care center for Medicare certification.