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
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-2	Family Medical Spenddown Worksheet
W-3	E&D Spenddown Estimator Tool
W-4	TOP Worksheet
W-4.1	Applicant – Transfer of Property Calculator Instructions
W-4.2	Recipient – Transfer of Property Calculator Instructions
W-9	Transfer of Property Worksheet 7-23
W-9 (2)	Transfer of Property Worksheet 7-22
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

Access the applications and associated materials listed below in the next three categories on the Apply Now page.

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
	User Access for KEESM SSP Portal

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