Informal Dispute Resolution (Idr) Request Form - Kansas Department Of Health And Environment


Informal Dispute Resolution (IDR) Request Form
This form and other information about the IDR process are available online at
The form located on the reverse side of this document must be submitted with all requests for an IDR.
Submission of the IDR Request Form
Fax or email this completed form to the IDR Coordinator at (785) 291-3419 or email
The IDR must be received within 10 calendar days of the agency receipt of the Statement of Deficiencies.
Requests received after day 10 will not be considered. The day the agency receives the Statement of Deficiency
is day zero. If the designated due date falls on a Saturday, Sunday or legal holiday, the due date is the next
business day.
Assure that the form is complete and legible.
Submission of Supporting Documentation
Supporting documentation should be mailed or sent via UPS or FedEx and must be postmarked by the 5
calendar day
after submitting the request form. The address is:
Home Health Informal Dispute Process Coordinator
Kansas Department of Health and Environment
Health Facilities Program
1000 SW Jackson St., Suite 330
Topeka, KS. 66612
Documentation submitted postmarked after this date will not be considered during the IDR process review.
o Supporting documentation should be separated by deficiency and well-organized.
o Do not submit supporting documentation in a three-ring binder or presentation binder.
o Do use tabs to organize your packet.
o Do not use staples. Do use binder or paper clips to organize sections, if needed.
o Number all pages for example, Page 1 of 6, or Exhibit 1, etc.
o Highlight or circle areas you would like to call attention to.
o You may submit copies printed back-to-back, however check copies for the ability to read and for clarity.
The IDR Packet must include:
o A fully completed form, Informal Dispute Resolution (IDR) Request Form.
o Five (5) copies of the agency’s supporting documentation. The specific reason each federal Condition
tag is being disputed, e.g., disagreement with the tag that was chosen, availability of supporting
information that disputes or further clarifies the facts, or errors in documentation on the Statement of
Deficiencies (SOD). Important points must be highlighted on submitted documents or detailed in a
cover letter.
Meetings are limited to one hour in length. Face-to-face conferences are held in Topeka, Kansas.
Key Point
The Home Health Agency must still submit an acceptable Plan of Correction within 10 calendar days, despite the
request for an IDR.


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