Policy Forms

Policy Forms List

• 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	Datos de Determinación de Incapacidad Informe de Caso de Asistencia Médica
  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
  ES-3165	Working Healthy Premiums
  ES-3166	Notification of PACE Information
  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-3822A	Statement of Continuing Cancer Treatment Medical Assistance – BCC Program
  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
  KC-4501	Facility Birth Reporting form for Medicaid Deemed Newborns
  KC-4510	Tax Information and Relationship (TIAR) form
  KC-4520	Requesting Tax HH for non-household members
  KC-4520S	Requesting Tax HH for non-household members – Spanish
  KC-5150	Self-Employment worksheet
  KC-5150S	Self-Employment worksheet – Spanish
  KC-6501	KDHE Civil Rights Complaint
  MS-2156	Medical Review of Emergency Services for SOBRA
  MS-2126	Notification of Facility Admission/Discharge
  MS-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
  	TPL Beneficiary Insurance Premium Payment Assistance
  	Notice of Withdrawal of Appeal
  	Beneficiary Request for Medicaid Fair Hearing

• Internal Forms

  Form Number	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-3104.5	Determination of Need (Medical Assistance) 4-20
  ES-3104.6	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-20
  	Determination Worksheet of Pickle Eligibiles and Other Protected Medical Groups 1-19
  ES-3162	Resource Assessment Allowance Determination 1-20
  	Resource Assessment Allowance Determination 7-19 v2
  ES-3163	Income Allowance Determination Form 07-20
  	Income Allowance Determination Form 1-20
  ES-3170	Beneficiary/Patient Spenddown Billed Form
  PA-3103.5	SSI Disregard Worksheet (IL and HCBS Only)
  R-1	Medical Subrogation Referral – Adoption
  R-2	Medical Subrogation Referral – Injury
  KC-5735	Medical RDB Request
  KC-4000	Confidentiality and Non-disclosure Form

• Archive of forms

  Form #	Form Name
  ES-3104.5	Determination of Need (Medical Assistance) 4-20
  	Determination of Need (Medical Assistance) 7-19
  	Determination of Need (Medical Assistance) 4-19
  	Determination of Need (Medical Assistance) 9-18
  	Determination of Need (Medical Assistance) 4-18
  ES-3104.6	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-20
  	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-19
  	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 7-18
  	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 4-18 (corrected)
  	Determination Worksheet for Pickle Eligiblies and Other Protected Medical Groups 1-17
  	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-16
  	Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-15
  ES-3162	Resource Assessment Allowance Determination 1-20
  	Resource Assessment Allowance Determination 7-19 (1-19 corrected)
  	Resource Assessment Allowance Determination 1-18
  	Resource Assessment Allowance Determination 2-17
  	Resource Assessment Allowance Determination 11-16
  	Resource Assessment Allowance Determination 1-15
  ES-3163	Income Allowance Determination Form 7-20
  	Income Allowance Determination Form 1-20
  	Income Allowance Determination Form 7-19
  	Income Allowance Determination Form 1-19
  	Income Allowance Determination Form 7-18
  	Income Allowance Determination Form 1-18
  	Income Allowance Determination Form 7-17
  	Income Allowance Determination Form 2-17
  	Income Allowance Determination Form 1-15
  ES-3165	Working Healthy and Premium Information 4-20
  	Working Healthy and Premium Information 4-19
  	Working Healthy and Premium Information 10-18 (4-18 corrected)
  	Working Healthy and Premium Information 4-18
  	Working Healthy and Premium Information 7-17