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
When a change in status occurs that does not effect the provider's eligibility to do business with the agency (i.e., - name change on license but no lapse in licensure
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https://content.dcf.ks.gov/EES/KEESM/current/keesm10030.htmView duplicates
resource will not be used, (4) report a change in the placement resource and/or type of care, (5) report a change of address, and 6) close an ICPC case
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It is an extremely useful tool
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_9000_Forms/PPS9135_instr.docView duplicates
Provide DOB, race, gender and address for all persons age 10 and up. Only list foster
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A move or change of ownership indicates an Initial application packet is required
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL_forms/FosterHomeInitialLicensingApplicationChecklist.pdf
State of Kansas ADOPTIVE PLACEMENT AGREEMENT PPS 5343 Department for Children and Families Rev
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a. Change of address
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Name Address Telephone Type of Information
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Residential Address
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5343.pdf
What is the Child Care Provider Handbook? 5
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SECTION II: General Information for All DCF Child Care Providers 6
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Violations of the Provider Agreement 9
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Sample Consent for Medical Care Form
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https://content.dcf.ks.gov/ees/KEESM/Robo02-25/NewForms02-25/C10.docx
Change in status with sponsoring agency regarding health and safety standards
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Change in operation (e.g., name change, address, telephone numbers, ownership, household members
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https://content.dcf.ks.gov/EES/KEESM/Current/keesm10034.htmView duplicates
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
HOW DO I REPORT A CHANGE OF ADDRESS TO THE KANSAS PAYMENT CENTER
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HOW DO I CHANGE FROM DIRECT DEPOSIT TO PREPAID DEBIT CARD
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https://www.dcf.ks.gov/services/CSS/Documents/KPC_FAQs for Payment Received_v2.pdf
Yes No Date of Change: Date of change: 6. Youth became emancipated
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Yes No Date of Change: Date of change: 9. Youth has accessed Independent Living Services and
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_6000_Forms/PPS6320.doc