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Informal Dispute Resolution (Idr) Request Form - Kansas Department Of Health And Environment Page 2

KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT

Informal Dispute Resolution (IDR) Request Form

Name of Agency _______________________________________ Facility ID ___________________________________

Agency Contact Name ___________________________________ Telephone __________________________________

Contact Email Address _______________________________________________________________________________

Mailing Address ________________________________________ City _____________________ Zip ______________

Survey Exit Date __________________

Date CMS-2567 SOD Received _________________________________

Type of IDR Request (Select One)

□ Desk Review

□Telephone Conference

□ Face-to-face

Conference

Fill in this section ONLY if the facility will be represented by an attorney. If an attorney is listed, all correspondence will be directed to this

person; not the facility. The agency may have an attorney present ONLY if this disclosure is completed, so that KDHE’s attorney may also be

in attendance.

Attorney Name ________________________________________ Firm Name _______________________________

Mailing Address ____________________________________ City __________________ State ____ Zip _________

Telephone Number ______________________________________ Email ___________________________________

List all Deficiencies (Tags) that you are disputing. Only the deficiencies listed will be reviewed.

Submitted by ________________________________________________ Date ________________________________

For Office Use Only—DO NOT WRITE BELOW THIS LINE

Date Received: __________________ by ______________________________

Verification Letter Issued on ________________________________________(date)

Informal Dispute Resolution (Idr) Request Form - Kansas Department Of Health And Environment Page 2