Prior to applying for certification, please read and understand the conditions of participation and service requirements for which you are seeking certification.
Assisted living service is a service that promotes aging in place by supporting a consumer's independence, choice, and privacy through the provision of one or more components of the service which are a personal care service, a supportive service, an on-duty response service, meals, social and recreational programming, a non-medical transportation service, and a nursing service.
Documentation you will be required to submit:
Registration with the Ohio Secretary of State: A copy of registration certificate with the Ohio Secretary of State.
Ohio Bureau of Workers’ Compensation Certificate: A copy of current certification in good standing with the Ohio Bureau of Workers’ Compensation.
Certificate of Commercial Liability Insurance: A copy of current policy of minimum of one million dollars in commercial liability insurance.
Employee Dishonesty or Property Damage Insurance: A copy of current insurance policy for employee dishonest or property damage to others. This requirement can be a warranty, surety, or business services bond.
Table of Organization: A copy of a table of organization that includes the full name of each position and indicates lines of authority.
Copy of Residential Care Facility (RCF) License & Initial Survey completed by ODH: Residential Care Facility (RCF) license issued by the Ohio Department of Health (ODH) and a copy of the initial survey completed by the ODH identifying the rooms covered under the RCF license. (Please Note: this is not an Adult Care Facility license issued by the Ohio Department of Mental Health.)
Pages 1 & 2 of the Long-Term Care Consumer Guide: This guide provides information about nursing homes and assisted living facilities to help consumers, family members and professionals search for the appropriate facility to meet an individual’s needs. This form will be provided for download during the online application process.
Completed and Signed W-9: This form will be automatically completed and available to download for signature during the online application process.
Ohio Health Plans Provider Enrollment Application/Time Limited Agreement for Organization: This form will be automatically completed and available to download for signature during the online application process.
Proof of Residency: Evidence that applicant/CEO has been a resident of Ohio for the last five consecutive years. Acceptable documentation includes: valid driver's license; notification of registration as an elector; a copy of an officially filed federal and state tax form identifying the applicant's permanent residence; any other documentation the responsible entity considers acceptable showing evidence the applicant has been a resident of Ohio for the past five years. If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
FBI Background Check: If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
Non-Disclosure Statement: This form will be available to download for signature during the online application process.
Required documentation can be submitted by:
Upload directly to application
to submission. prior
Fax to 614-466-9812 or 614-466-5741.
Ohio Department of Aging
50 West Broad Street, 9 th Floor
Columbus, OH 43215
PLEASE NOTE: documentation emailed to our office will not be accepted and can delay the processing of your application.
I acknowledge I have read and understand the above information.