Provider Services – Appeal/Waiver Application

The appeal will be heard during the monthly panel meeting and a decision letter will be sent to the submitter within 48 hours.

Emergency hardship waivers are requests by applicants or licensees to excuse noncompliance with a specific child care licensing rule due to urgent, significant, and unexpected situations outside of the applicant’s or licensee’s control such as natural disasters, infectious disease outbreaks, mold outbreaks, acts of nature resulting in structural damage to the child care facility, or an immediate, child/youth-specific, emergency placement or situation that might disrupt placement or pose a safety risk to children/youth in out-of-home placement. An emergency appeal will be heard as soon as possible if it is determined to be a true emergency. Please check the box BELOW if your HARDSHIP appeal falls into one of these categories and must be heard as an emergency

If the form is not completed in its entirety, it will be returned and could cause a delay in a decision regarding your appeal request.

Reason for Appeal *

• Hardship
• Stringency
• Contracted Beds Eligibility

Emergency Appeal

• Yes

Emergency Appeal is defined as an immediate child(ren) specific placement or situation which may jeopardize or disrupt a placement, or a safety risk to a child(ren). Appeal will be heard immediately with a decision letter sent to the submitter within 48 hours.

Provider Name *

License # *

Placing Authority *

Mailing Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Name *

First

Last

Phone *

Email *

Type of Facility *

• Day Treatment
• Specialized Group Facility
• CPA/Foster Home/Adoption
• Specialized Residential Treatment Center
• County/Foster Home/Adoption
• Psychiatric Residential Treatment Facility
• Homeless Youth Shelter
• Residential Child Care Facility
• Qualified Residential Treatment Program

Type of Facility *

• Day Treatment
• Specialized Group Facility
• CPA/Foster Home/Adoption
• Specialized Residential Treatment Center
• Psychiatric Residential Treatment Facility
• Homeless Youth Shelter
• Residential Child Care Facility
• Qualified Residential Treatment Program

List all contracted facilities *

• Southern Peaks
• Third Way Centers
• Laradon Hall
• Specialized Alternatives for Families and Youth (SAFY)
• Envoi Associates

For County/CPA Foster Home Appeals Only

FFH Name *

License # *

FFH Location Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Licensed Capacity and Ages *

Date of Original License *

Date of Last Visit By This Department *

*Note: This is a requirement. If you are appealing an ROI that you believe is being too stringently applied, you must provide a copy of the ROI you are appealing and must also be included at the time the appeal is submitted. (Counties are excluded from this requirement).

What is the date this hardship was created? *

**Note: Request for waiver must be submitted within 60 days of the date on which the rule allegedly was too stringently applied or created the hardship. The 60 day timeframe begins the date you receive your ROI. Appeal forms received after this timeframe will not be processed.

What is the date the eligibility was denied? *

List the specific rule number(s) for this appeal *

The Rule Number(s) is REQUIRED and your appeal will not be valid without the required rule number(s). You may only appeal one issue or violation per appeal form.

Describe the current circumstance that is creating a hardship or stringency to the agency/facility/home. Be specific, and provide examples, if applicable: *

Describe why eligibility criteria has been applied to Stringently? *

Identify the safety concerns related to the hardship or stringency: *

Describe the hardship or stringency and the impact that circumstance creates on the agency/facility/home. Include a description of any attempts to comply with the rule: *

Describe specifically what the placing authority is asking to be reassessed *

Describe specifically what the agency/facility/home is asking to be waived and how the agency/facility/home will address the identified safety concerns if the appeal is to be accepted: *

Describe how the agency proposes to mitigate the safety concerns if the appeal is accepted *

Additional exhibits or information

Click or drag files to this area to upload. You can upload up to 10 files.

Below is a listing of exhibits or information you may attach for the appeal panel to consider: Transcripts/verification of experience (required for staff qualification appeals), staffing patterns, supervision plans, a floor plan of the facility (required for foster homes over capacity appeals), letters from affected parents/workers, Health and/or Fire Department Inspection, and any other pertinent information. PLEASE DO NOT SEND PICTURES OF CHILDREN. Attach up to 10 additional files, not to exceed 15mb of data.

Additional exhibits or information

Click or drag files to this area to upload. You can upload up to 10 files.

- Official notice of eligibility determination from State staff
- Application submitted to State staff for eligibility - determination
Optional:
- Neuropsychological evaluations
- Education plans
- Service plans or other permanency related documents
- Other mitigating information

Report of Inspection

Click or drag files to this area to upload. You can upload up to 2 files.

Schedule for Family Foster Homes

Click or drag a file to this area to upload.

The Schedule for Family Foster Homes is required for all foster home appeals and appeals cannot be processed if this form is not included with the request. This form lists all of the children in the home (foster, adoptive, and biological) to include their names, ages, and date of placement (if applicable). Be sure to include the children for which you are appealing to have placed in the foster home. If you are appealing a transfer of a foster home from one agency or county department of human services to another agency, please submit letters of support from caseworkers/utilization review managers for all youth in the home, as well as letters of support from a GAL/CFY, if applicable.

I attest that the information contained in this request for an appeal is accurate and all relevant information has been included. I understand that providing false and misleading information to the Colorado Department of Human Services could result in my agency or facility being fined as much as $250 a day for the first day, $500 for the second day, and $1000 a day for the third day and subsequent days to a maximum of $10,000. *

Clear Signature

Sign here

Submit