Transcription of In-Home Services License Application Packet
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In-Home Services License Application Packet
DOH 505-052 June 2021In- home Services License Application PacketContents: 1. 505-052 ..Contents List / Mailing Information ..1 Page2. 505-053 .. Application Instructions Checklist ..3 Pages3. 505-109 .. License Page4. 505-051 .. In-Home Services Application ..5 Pages5. 505-055 ..Disclosure Statement ..1 Page 6. 505-137 ..Full-Time Equivalent (FTE) Worksheet ..2 Pages7. RCW/WAC and Online Website Links ..1 Page In order to process your request:Mail your Application with initial documentation and your check Send other documents not sent or money order payable to: with initial Application to:Department of Health In-Home Services Credentialing Box 1099 Box 47877 Olympia, WA 98507-1099 Olympia, WA 98504-7877 Contact
F Application Fee: You can check the online fee page for current fees. F On page one of the application, indicate type of application—new, change of ownership, amended or renewal. • New - First time requesting an In-Home Services Agency license. • Change of Ownership - When name of legal owner/operator changes
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