1. Long-Term Care (LTC) Providers

All Long-Term Care providers must complete and submit the following documents:

• Long-Term Care Provider Application  
• Certificate of Liability Insurance, see requirements   
• W-9 Form     
• Employee Rosters reflecting Employee Name, Hire Date, Title.
• Civil Rights Compliance Form
• Additional page 3, complete this page for each location
• Additional page 4, if needed

2. Licensed or Certified Residential & Adult Day Care Facilities

In addition to the documents in number 1, submit the following for each facility location:

• Copy of License or Certification for each location
• Copy of your Program Statement for each location
• The last DQA or Certifying Agency survey (with plan of correction, if applicable)

3. Providers seeking iCare 1-2 Bed AFH Certification

In addition to the documents in number 1, please complete the following:

• 1-2 Bed AFH Certification requirements
• 1-2 Bed AFH Certification form
• Submit financial documentation such as bank statement, savings, investments, etc. that reflects funds or income that may be used to continue the operation of the facility for 30 days based on the total operating costs for a 1-2 Bed AFH
• If you are renting the 1-2 Bed AFH location, submit a copy of the rental agreement reflecting the landlord's approval to operate a business from the address you are seeking Certification