Notification of Grant Award (NOGA) Under Federal Grant Award (CFDA) Number 93.558 DCF Award Number EES-2021-JAG-01 THIS AGREEMENT MADE THIS DAY BETWEEN Kansas Department for
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/Jobs for America's Graduates JAG NOGA SFY21.pdf
for Amendment Use this form to request a change of the family foster home license capacity
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Submit the completed request and supporting documents to DCF.FCLExceptions@ks.gov
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Address
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL 407 Family Foster Home Request for Amendment.pdf
to DCF any time there is a placement change, address change, or level of care change
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Check Change of Venue if: This is an acknowledgment of a referral due to a change of venue
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120_Instr.doc
obtain written approval from the secretary before making any change in any of the following
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the school district at least 90 days before the anticipated date of any proposed change
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FC_Residential_Center_Group_Boarding/Res_Center_Grp_Boarding_Regs.pdf
new application shall be required for each change of ownership, sponsor, or address of the facility
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FC_AttendantCare/Regulations_for_Attendant_Care.pdf
Placement Change
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Send Medicaid card to the current placement address indicated above
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Name of Insurance Company: Insurance Company's Address: Employer: Medical: Yes No
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5460.doc
Department for Children and Families 07/2023
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The purpose of the Gail Finney
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(10) address the court regarding any proposed placement or placement change in accord with KSA 38-2262, and
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5138.docx
III Provider Staff Assigned: If change, list reason: Address: Worker Phone #: 24 Hour Access Phone
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Same school with grade level change
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School Change: District
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120.doc
Add an entry to the tracker for the Purple team to claim and follow up on the address change
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to reach the consumer to obtain a new address, release the task and reassign the task to the
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https://content.dcf.ks.gov/ees/KEESWebHelp/NonMedical-KEESWebHelp/EBT_Undeliverable_Mail_Process.htm
REV. Jan -2025
Page 2 of 2
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State of Kansas FC/AD NOTIFICATION OF MOVE/PLACEMENT/CHANGE PPS 5120
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Placement Name and Physical Address
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Change of status for sibling(s) remaining in the home
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120.docx