Request for Approved Program Capacity & Noncontiguous Clearance Attachment #1 SECTION A Legal Entity Name: Street Address/City/State/Zip: Contact Name: Phone Number (include area code): Email Address: MPI #: Service Location Code: Check the type of service location that applies to the request RESIDENTIAL SERVICE LOCATIONS COMMUNITY PARTICIPATION SUPPORT FACILITIES Licensed 55 Pa. Code Licensed 55 Pa. Code Licensed 55 Pa. Code ☐ Unlicensed Life Sharing ☐ Ch. 6400 Community Living Home Ch. 6500 Family Living Home Ch. 2380 Adult Training Facility Home Licensed 55 Pa. Code Ch. 6400 Licensed 55 Pa. Code Licensed 55 Pa. Code Licensed 55 Pa. Code ☐ ☐ Community Living Home Ch. 3800 Child Residential and Ch. 5310 Community Ch. 2390 Vocational Facility (For Respite Only Homes) Day Treatment Residential Rehabilitation Unlicensed Residential Habilitation Supported Living Licensed 6 Pa. Code ☐ Chapter 11 Older Adult Daily Living Centers Service Location Street Address/City/State/Zip: Check the Type of Request Request For a New Community Participation Support Facility to Establish Noncontiguous Clearance (Prior to Requesting Approved Program Capacity) (Proceed to Section B) Request For a New Licensed or Unlicensed Residential Service location to Establish Noncontiguous Clearance to Requesting Approved Program Capacity) (Proceed to Section C) Request to Establish Approved Program Capacity for a new Licensed Residential Service Location Under 55 Pa. Code Ch. 6400 Community Living Home (including Respite Only Homes), Ch. 6500 Family Living Home, Ch. 5310 Community Residential Rehabilitation or Ch. 3800 Child Residential and Day Treatment Facility (Proceed to Section D) Request to Establish Approved Program Capacity for a new Unlicensed Residential Service Location including Supportes Living, Life Sharing, and Residential Habilitation homes. (Proceed to Section E) Request to Change Current Approved Program Capacity For a Licensed or Unlicensed Residential Service Location (Proceed to Section F) Request to Close a Licensed or Unlicensed Residential Service Location (not including Supported Living) or a Community Participation Support Facility (Proceed to Section G) SECTION B REQUEST FOR A NEW COMMUNITY PARTICIPATION SUPPORT FACILITY TO ESTABLISH – NONCONTIGUOUS CLEARANCE
Request for Approved Program Capacity & Noncontiguous Clearance Attachment #1 SECTION A Legal Entity Name: Street Address/City/State/Zip: Contact Name: Phone Number (include area code): Email Address: MPI #: Service Location Code: Check the type of service location that applies to the request RESIDENTIAL SERVICE LOCATIONS COMMUNITY PARTICIPATION SUPPORT FACILITIES Licensed 55 Pa. Code Ch. 6400 Community Living Home Licensed 55 Pa. Code Ch. 6500 Family Living Home ☐ Unlicensed Life Sharing Home ☐ Licensed 55 Pa. Code Ch. 2380 Adult Training Facility Licensed 55 Pa. Code Ch. 6400 Community Living Home (For Respite Only Homes) Licensed 55 Pa. Code Ch. 3800 Child Residential and Day Treatment ☐ Licensed 55 Pa. Code Ch. 5310 Community Residential Rehabilitation ☐ Licensed 55 Pa. Code Ch. 2390 Vocational Facility Unlicensed Residential Habilitation Supported Living ☐ Licensed 6 Pa. Code Chapter 11 Older Adult Daily Living Centers Service Location Street Address/City/State/Zip: Check the Type of Request Request For a New Community Participation Support Facility to Establish Noncontiguous Clearance (Prior to Requesting Approved Program Capacity) (Proceed to Section B) Request For a New Licensed or Unlicensed Residential Service location to Establish Noncontiguous Clearance to Requesting Approved Program Capacity) (Proceed to Section C) Request to Establish Approved Program Capacity for a new Licensed Residential Service Location Under 55 Pa. Code Ch. 6400 Community Living Home (including Respite Only Homes), Ch. 6500 Family Living Home, Ch. 5310 Community Residential Rehabilitation or Ch. 3800 Child Residential and Day Treatment Facility (Proceed to Section D) Request to Establish Approved Program Capacity for a new Unlicensed Residential Service Location including Supportes Living, Life Sharing, and Residential Habilitation homes. (Proceed to Section E) Request to Change Current Approved Program Capacity For a Licensed or Unlicensed Residential Service Location (Proceed to Section F) Request to Close a Licensed or Unlicensed Residential Service Location (not including Supported Living) or a Community Participation Support Facility (Proceed to Section G) SECTION B – REQUEST FOR A NEW COMMUNITY PARTICIPATION SUPPORT FACILITY TO ESTABLISH NONCONTIGUOUS CLEARANCE
ODPANN-071-18-Attachment-1-Form.docx