Form KDOC-0086 "Kdoc Services Placement Agreement" - Kansas

What Is Form KDOC-0086?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2011;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form KDOC-0086 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0086 "Kdoc Services Placement Agreement" - Kansas

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KDOC Services Placement Agreement
Name of Youth: _________________________________
Date of birth: _______________________
Medicaid ID Number: ___________________
Social Security#: ____________________
This agreement, entered into on this __________ day of ____________________, __________ shall be approved for a period not to
exceed __________ days. This agreement shall expire on the __________ day of ____________________, __________. This
agreement
is
between
the
KDOC
through
its
designated
Community
Supervision
Agency
and
the
provider
_________________________________________. The provider and Community Supervision Agency agree to follow all
requirements as set forth in this agreement for the service type indicated below.
Level of Service:
_____
Therapeutic Family Foster Home
_____
Youth Residential Center I
_____
Emergency Shelter
_____
Satellite Family Foster Home
_____
Youth Residential Center II
_____
Maternity Foster Home
_____
Emergency Family Foster Home
_____
Juvenile Justice Foster Care
_____
Family Foster Home
_____
Community Integration Program
_____
Residential Maternity Care
_____
Specialized Family Foster Home
_____
Transitional Living Program
Upon admission, an initial KDOC Placement Agreement shall be completed for a period not to exceed 90 calendar days for all
placements listed above (excluding Emergency Shelters). All subsequent KDOC Placement Agreement extensions shall be completed
for a period not to exceed 60 calendar days for all placements (excluding Emergency Shelters).
The initial KDOC Placement Agreement for Emergency Shelter placements shall be completed for a period not to exceed 30 calendar
days. Please see the Emergency Shelter standards criteria regarding extensions and complete the KDOC Placement Agreement
accordingly (if approval is granted).
The Provider hereby agrees:
To abide by applicable childcare licensing regulations of the State of Kansas, adhere to the terms detailed in your KDOC
contract, and fulfill all standard requirements specific to this level of service within the KDOC Provider Handbook.
To allow the juvenile to remain in placement unless it has been mutually agreed to transition the juvenile to another
placement, and inform the community supervision officer of reasons for which they can no longer meet the juvenile’s needs.
The Community Supervision Agency (CSA) hereby agrees:
The Community Supervision Officer is responsible for the completion of this form (initial and all renewals).
To authorize payment at the rate stated in the Provider Handbook for the respective placement type indicated on this
agreement. Authorization shall be for all placement days provided in accordance with the Provider Handbook, excluding the
day of discharge.
To provide a Medicaid card issued by the State of Kansas to Provider or for a non-Medicaid eligible youth to authorize
alternative payment for necessary medical care.
To provide notice to the provider before removing child. No notice is required if said removal is court ordered, is done for
the protection of the child, or is no longer supported by the CBST or supervision plan process.
The Parties agree that this agreement is supplemental and in addition to any other written agreements or contracts between the parties
which may exist or may hereafter be entered into. Failure of the provider to provide placement services as specified may result in the
withholding of authorization for payment.
CSA: _____________________
Work Phone Number: _____________________
Fax Number: ______________________
_________________________________________________
_________________________________________________
Community Supervision Officer Signature
Date
Provider Signature
Date
_________________________________________________
CSA Emergency/On-Call Number: ___________________
CSA Supervisor Signature
Date
State of Kansas
Kansas Department of Corrections
Form: KDOC-0086
Revised May 2011
KDOC Services Placement Agreement
Name of Youth: _________________________________
Date of birth: _______________________
Medicaid ID Number: ___________________
Social Security#: ____________________
This agreement, entered into on this __________ day of ____________________, __________ shall be approved for a period not to
exceed __________ days. This agreement shall expire on the __________ day of ____________________, __________. This
agreement
is
between
the
KDOC
through
its
designated
Community
Supervision
Agency
and
the
provider
_________________________________________. The provider and Community Supervision Agency agree to follow all
requirements as set forth in this agreement for the service type indicated below.
Level of Service:
_____
Therapeutic Family Foster Home
_____
Youth Residential Center I
_____
Emergency Shelter
_____
Satellite Family Foster Home
_____
Youth Residential Center II
_____
Maternity Foster Home
_____
Emergency Family Foster Home
_____
Juvenile Justice Foster Care
_____
Family Foster Home
_____
Community Integration Program
_____
Residential Maternity Care
_____
Specialized Family Foster Home
_____
Transitional Living Program
Upon admission, an initial KDOC Placement Agreement shall be completed for a period not to exceed 90 calendar days for all
placements listed above (excluding Emergency Shelters). All subsequent KDOC Placement Agreement extensions shall be completed
for a period not to exceed 60 calendar days for all placements (excluding Emergency Shelters).
The initial KDOC Placement Agreement for Emergency Shelter placements shall be completed for a period not to exceed 30 calendar
days. Please see the Emergency Shelter standards criteria regarding extensions and complete the KDOC Placement Agreement
accordingly (if approval is granted).
The Provider hereby agrees:
To abide by applicable childcare licensing regulations of the State of Kansas, adhere to the terms detailed in your KDOC
contract, and fulfill all standard requirements specific to this level of service within the KDOC Provider Handbook.
To allow the juvenile to remain in placement unless it has been mutually agreed to transition the juvenile to another
placement, and inform the community supervision officer of reasons for which they can no longer meet the juvenile’s needs.
The Community Supervision Agency (CSA) hereby agrees:
The Community Supervision Officer is responsible for the completion of this form (initial and all renewals).
To authorize payment at the rate stated in the Provider Handbook for the respective placement type indicated on this
agreement. Authorization shall be for all placement days provided in accordance with the Provider Handbook, excluding the
day of discharge.
To provide a Medicaid card issued by the State of Kansas to Provider or for a non-Medicaid eligible youth to authorize
alternative payment for necessary medical care.
To provide notice to the provider before removing child. No notice is required if said removal is court ordered, is done for
the protection of the child, or is no longer supported by the CBST or supervision plan process.
The Parties agree that this agreement is supplemental and in addition to any other written agreements or contracts between the parties
which may exist or may hereafter be entered into. Failure of the provider to provide placement services as specified may result in the
withholding of authorization for payment.
CSA: _____________________
Work Phone Number: _____________________
Fax Number: ______________________
_________________________________________________
_________________________________________________
Community Supervision Officer Signature
Date
Provider Signature
Date
_________________________________________________
CSA Emergency/On-Call Number: ___________________
CSA Supervisor Signature
Date
State of Kansas
Kansas Department of Corrections
Form: KDOC-0086
Revised May 2011