Forms

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Forms are sorted by those that are strictly for internal purposes and communication and those that are sent outside of the agency. Forms have retained their original form number where applicable.

External Forms

Form #	Form Name
DD-1103	Authorization to Disclose Information to KDHE-DDS
DD-1103S	Autorización para Revelar Información a KDHE-DDS
DD-1104	Disability Determination Request Medical Assistance Case
DD-1105	Disability Determination Data/Report Medical Assistance Case
DD-1105S	Informe/Datos de Determinación de Discapacidad
DD-1106	Medical Onset Date Verification
ES-3121	Letter to Veteran’s Administration for Benefit Verification
ES-3122	Veterans Administration – Potential Benefits Request
ES-3153	Statement of Continuing Eligibility (Working Healthy)
ES-3159	HCBS Client Obligation Informational Agreement
ES-3160	Notification of KanCare HCBS Services
ES-3161	Notification of KanCare, HCBS Changes and Updates
KC-3161	Reported Change Chart
ES-3165	Working Healthy Premiums
ES-3165S	Working Healthy Premiums – Spanish
ES-3165	Working Healthy Premiums 5-23
ES-3167	Annuity Information Letter
ES-3167A	Annuity Information Request form
ES-3168	Prepaid Funeral Agreement
ES-3169	Irrevocable Assignment of Benefits of Life Insurance/Annuity Policy
ES-3171	Irrevocable Collateral Assignment of Life Insurance Proceeds
ES-3172	Life Insurance Information Request Form
ES-3822A	Statement of Continuing Cancer Treatment Medical Assistance
ES-3900	Tell Us If You Have A Disability
ES-3903	Presumptive Medical Disability Questionnaire
ES-3904	HIPAA Compliant Authorization to Disclose Information to KDHE
ES-4501	Facility Birth Reporting form for Medicaid Deemed Newborns
ES-4510	Tax Information and Relationship (TIAR) Form Also available in KEES as V777 in both English and Spanish
ES-4520	Requesting Tax HH for non-household members
ES-4520S	Requesting Tax HH for non-household members – Spanish
ES-4530	Pre-tax Deduction Form
ES-4530S	Pre-tax Deduction Form - Spanish
ES-5150	Self-Employment worksheet
ES-5150S	Self-Employment worksheet- Spanish
ES-6501	KDHE Civil Rights Complaint
ES-2126	Notification of Facility Admission/Discharge
ES-2156	Medical Review of Emergency Services for SOBRA
ES-2156-A	SOBRA Referral Letter
ES-2156-B	SOBRA Referral Letter – Second request
ES-2504	HIPPS Referral
M-1	Statement of Intent to Return Home
M-2	Notice of Intent to Transfer Resources
M-3	Notice of Intent to Allocate Income
M-5	Medicaid Transfer of Property Decision
P-2	Statement of Medical Necessity
P-7	Declaration of Identity – Child
P-8	Third party – Declaration of Citizenship
P-9	Declaration of Identity – Disabled Adult
N/A	TPL Beneficiary Insurance Premium Payment Assistance
N/A	State Fair Hearing forms

Internal Forms

Form #	Form Name
B-6.1	B-6.1 Annuity Clearance Request Form 1-20
B-6.2	B-6.2 Trust Clearance Request Form 1-20
ES-3103.5	SSI Disregard Worksheet (IL and HCBS only) 7-21
ES-3104.5	Determination of Need (Medical Assistance 4-23)
ES-3104.6	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-24
ES-3104.7	Income Allocation Worksheet 7-21
ES-3162	Resource Assessment Allowance Determination 1-24
ES-3163	Income Allowance Determination Form 1-24
ES-3170	Beneficiary/Patient Spenddown Billed Form
KC-4000	Confidentiality and Non-disclosure Form
KC-5150	For internal use only – Self-employment worksheet
KC-5373	Medical RDB Request
R-1	Medical Subrogation Referral – Adoption
R-2	Medical Subrogation Referral – Injury