245d pre application worksheet 2026

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  1. Click ‘Get Form’ to open the 245D Pre-Application Worksheet in the editor.
  2. Begin by determining the type of license holder. Choose between 'individual' or 'non-individual' and provide the necessary details such as legal name, tax ID, and contact information.
  3. Designate an authorized agent from your controlling individuals. Ensure you complete and upload the notarized signature form as a PDF.
  4. Identify all controlling individuals involved in your organization. List their full names, positions, and contact details accurately.
  5. Specify the types of services you intend to provide under the 245D license. Mark the relevant basic and intensive support services on the form.
  6. Enter your program name and location details, ensuring that you include all necessary addresses and phone numbers.
  7. Upload additional required documentation as specified in the worksheet. Make sure each document is saved individually in PDF or Word format.
  8. Complete your online application by reviewing all entered information for accuracy before submitting it along with the application fee.

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The Home and Community-Based Services (HCBS) Settings rule features requirements for all residential and non-residential settings funded through Medicaid as part of HCBS. This includes adult day services, assisted living/HWS, memory care, group homes and employment services.
245D is the law that governs licensure of providers offering basic support services and intensive support services to recipients of DHS funding.
245D is the law that governs licensure of providers offering basic support services and intensive support services to recipients of DHS funding.

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