CONTINUING CARE PROVIDER
ANNUAL DISCLOSURE STATEMENT


This Disclosure Statement must be delivered to all prospective residents. This Disclosure Statement must be made available to current residents upon request. This disclosure must be made within 4 months of the end of your fiscal year every year and within 90 days of any ownership or management change to the provider or home.

PART I - GENERAL DISCLOSURES



Administrative Office:




Continuing Care Facility:




CEO/Executive Director/Comparable Official:




Type of Provider:
A.
B.
C.






PART II - ITEMIZED DISCLOSURES

Please read each item below, check the appropriate answer and provide the necessary documentation as requested by email to kid.addah@ks.gov
Incomplete applications cannot be processed.































PART III - ANNUAL AUDIT

Important information PLEASE READ:

The continuing care provider is required to have an annual certified audit prepared by a Certified Public Accountant and to provide a copy of the audit to the Kansas Insurance Department by email to kid.addah@ks.gov

A copy of this audit must be made available to any resident or perspective resident upon request.

This disclosure statement, and the information contained herein and provide hereto, is true and correct to the best of my knowledge.


By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.