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Appendix

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The Appendix contains documents and materials that support all medical programs. Documents that were previously released to support a policy implementation have now been added to the Appendix list. It is noted that some documents do not have a form number. Only documents previously assigned are listed with a form number. Documents are sorted by the purpose of the item, not by the program for which it is used.

Releases of Information

Form #	Form Name
KC-6100	Medical Representative Authorization Form
KC-6100S	Formulario de Autorización del Representante Médico
KC-6200	Facilitator Authorization Form
KC-6200S	Formulario de Autorización del Facilitador
KC-6110	Authorization for Release of Protected Health Information
KC-6110S	Autorización para la Divulgación de Información Protegida de Salud

Eligibility Processing

Form #	Form Name
P-1	Medical Necessity
P-4	Kelley Blue Book User Instructions
P-14	Where to find Death Information on EATSS Records
KC-1101	Family Medical Application Eligibility Processing Instructions
KC-1501	E&D Medical Application Eligibility Processing Instructions
KC-1801	SSP Online Application Eligibility Processing Instructions
KC-7011	Resource Documentation Requirements
KC-7012	CE Dates for Aid Codes Chart
KC-7013	Tiered Verification Chart
KC-7014	MAGI Building IBUs – Flow Chart
KC-7015	MAGI Individual Budget Unit (IBU) Examples
KC-7016	Applying the Income Rules for Children and Tax Dependents
KC-7017	Transitional Medical Scenarios
N/A	HCBS Termination Instructions

Financial

Form #	Form Name
F-8	Kansas Medical Standards - Current
F-8	Kansas Medical Standards 7-23
T-3	Life Estate Valuation Tables
T-4	Life Expectancy Table
T-5	Gambling Winnings - Income Budgeting Table
KC-7000	300 Percent Income Chart
KC-7004	Countable Exempt Income Chart
N/A	Acceptable Verification of Earned Income

Review Processing

Form #	Form Name
KC-1201	FM Pre-Populated Review Processing Instructions
KC-1601	E&D Pre-populated Review Processing Instructions
KC-7008	Skipped Review Chart
KC-7009	Pre-populated Review Processing Standards
KC-7017	Transitional Medical Scenarios
KC-7018	Individuals Discontinued at Passive Review
KC-7020	Review Scenarios - Eligibility Policy Guidance

Worksheets

Form #

Form Name

W-4

TOP Worksheet (2024)

W-4.1

Applicant – Transfer of Property Calculator Instructions

W-4.2

Recipient – Transfer of Property Calculator Instructions

W-9

Transfer of Property Worksheet 7-24

W-9 (2023)

Transfer of Property Worksheet 7-23

W-10

Annuity Evaluation Worksheet

W-14

MediKan Eligibility Worksheet

W-15

VA Potential Benefits Checklist

Citizenship and Alien Information

Form #	Form Name
A-1	Non-Citizen Qualification Chart
A-10	Systematic Alien Verification for Entitlement (Save) Handbook
A-11	INS Class of Admission Codes
A-12	Citizenship and Identity Verification for Medical Assistance

Application and Additional Information

Family Medical Applications and Materials

Form #	Form Name
KC-1100	Medical Assistance Application for Families with Children
KC-1100S	Solicitud de Asistencia Médica para Familias con Niños
KC-2100	Families with Children Brochure
KC-2100S	Asistencia Médica para Familias con Ninos
KC-2110	Helpful Hints for Families Card
KC-2110S	Tarjetaq de Consejos útiles para las familias

Elderly and Person with Disabilities Applications and Materials

Form #	Form Name
KC-1500	Medical Assistance Application for the Elderly and Persons with Disabilities
KC-1500S	Solicitud de Asistencia Médica para Personas Mayores de edad y Personas con Discapacidades
KC-1105	E&D Supplemental Application to the KC-1100
KC-1105S	Suplemento de la Solicitud para KC-1100S
KC-2500	Elderly and Persons with Disabilities Brochure
KC-2500S	Asistencia Médica para Personas mayores de edad y Personas con discapacidades
KC-2510	Helpful Hints for E&D Card
KC-2510S	Consejos útiles para la tarjeta E&D

Medicare Savings Applications and Materials

Form #	Form Name
ES-3100.8	Medicare Savings Program Application
ES-3100.8S	Solicitud / Renovación Planes de Ahorro Medicare
KC-2700	Medicare Savings Program Brochure
KC-2700S	Folleto del Programa de Ahorros de Medicare

Other Applications

Form #	Form Name
ES-3100.1a	Correctional Facility Inmate- Qualifying Event
ES-3100.3	Certification of Need for Tuberculosis Treatment
ES-3100.7	Application for Medical Coverage – BCC

Other Information

These are to be used with a Clearinghouse Slip sheet for mailing purposes

Form #	Form Name
M-6	Medicaid Application Signature Page
M-6S	Medicaid Application Signature Page- Spanish
M-7	Cover Letter for Unsigned Applications
M-7S	Cover Letter for Unsigned Applications- Spanish
M-8	Cover Letter for Unacceptable Signature
M-8S	Cover Letter for Unacceptable Signature - Spanish

Miscellaneous

Form #

Form Name

KC-5700

Rights and Responsibilities - English

KC-5700S

Rights and Responsibilities - Spanish

KC-7203

Voter Registration Companion Letter - English

KC-7203S

Voter Registration Companion Letter - Spanish

State of KS Voter Registration Form

Language Assistance Services

Document Upload Portal User Manual

Charts

Form #	Form Name
KC-6001	Administrative Roles Chart
KC-7004	Countable Exempt Income Chart
KC-7005	SSI Payment Status Codes
KC-7006	Eligibility Actions Following SSI Termination Chart
KC-7021	Extended Postpartum (PP) CE Examples Chart
KC-7022	Reported Address Change Verification Chart