Apply for a 245D-HCBS License

Required Documentation

For access to the 245D HCBS License application, you must complete the following:

245D Pre-Application Worksheet

Fill out form completely with all required information

*This will not be uploaded with the application, but is required to compile necessary information

Policies

• Drug and Alcohol Prohibition Policy

• Emergency Use of Manual Restraint (EUMR) Policy

• Grievance Policy

• Maltreatment of Minors Reporting and Internal Review Policy

• Service Suspension and Termination Policy

• Vulnerable Adults Maltreatment Reporting and Internal Review Policy

• Emergency Use of Manual Restraint

*It is highly encouraged that you use our sample policies for your program. They were developed by 245D HCBS Licensors and will ensure compliance with 245D Standards. Follow the highlighted instructions on the top of each document.

Applicant and License Holder Notarized Signature Form

Fill out Page 2 of the Authorized Agent Notarized Signature Form and sign in front of a Notary Public

Worker's Compensation Insurance Verification Form

Include your policy information, or indicate why you are exempt from this requirement, with a signature on the bottom

Organizational Chart

Indicate the highest authority in your program, including all Controlling Individuals

**NOTE**

All documents to be uploaded into the application and must be in a PDF or Microsoft Word format.

Background Studies

After you submit your 245D application, your Authorized Agent will receive an email from the DHS NETStudy Administrator with instructions for a NETStudy 2.0 account to submit background studies on all Controlling Individuals. These background studies for all Controlling Individuals must be submitted and cleared before your license can be issued. Be sure to monitor any Spam/Junk folders for the email correspondence.

Application Fees

Applicants submitting a 245D license application will pay the standard $500 application fee.

When You Are Ready To Apply

When you contact the 245D Licensing Unit for application access with all completed forms, please allow for 30-45 minutes for assistance with the application. You will work with a licensor, step-by-step through the application process to ensure accuracy and efficiency.

All of the required documents must be completed and uploaded to your computer in a PDF or Microsoft Word format prior to calling the HCBS Licensing Unit.

You must be prepared to pay an application fee at the time you complete your application with a licensor. This process is completed online and may be paid via Visa, MasterCard, or E-Check.

You can reach the 245D Licensing Unit at 651-431-6624.

Once your application has been received by the 245D HCBS Licensing Unit, we will review your application for all required fields and documents. Your application will be approved when the application and all materials meet compliance with 245D standards, and when the background studies for all Controlling Individuals have been cleared.

Please call us if you have any questions or concerns when preparing your materials for the 245D application process.

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