Policy Forms

Policy Forms List

• External forms

  New External Forms list 10/07/21

   

  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
  ES-3165	Working Healthy Premiums
  ES-3165S	Working Healthy Premiums- Spanish
  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-4530              Pre-tax Deduction Form

      KC-4530S           Pre-tax Deduction Form- Spanish

      KC-5150              Self-Employment worksheet 

      KC-5150S           Self-Employment worksheet- Spanish

      KC-6501              KDHE Civil Rights Complaint

  MS-2126	Notification of Facility Admission/Discharge
  MS-2156	Medical Review of Emergency Services for SOBRA

      MS-2156-A            SOBRA Referral Letter

      MS-2156-B            SOBRA Referral Letter – Second request

  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 #                        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

                           SSI Disregard Worksheet (IL and HCBS Only) 10-20

  ES-3104.5       Determination of Need (Medical Assistance) 7-21

                           Determination of Need (Medical Assistance) 4-21

  ES-3104.6       Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 7-21

                           Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-21                                                   Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 10-20       

  ES-3104.7       Income Allocation Worksheet 7-21

                           Income Allocation Worksheet 10-20

   

  ES-3162          Resource Assessment Allowance Determination 1-21

                          Resource Assessment Allowance Determination 1-20

   

  ES-3163          Income Allowance Determination Form 7-21

                          Income Allowance Determination Form 1-21

                     

  ES-3170          Beneficiary/Patient Spenddown Billed Form

   

  R-1                  Medical Subrogation Referral – Adoption

   

  R-2                  Medical Subrogation Referral – Injury

   

  KC-4000         Confidentiality and Non-disclosure Form

   

  KC-5150         For internal use only – Self-employment worksheet

   

  KC-5373         Medical RDB Request

   

• Archive of forms

  ES-3103.5                  

  SSI Disregard Worksheet (IL and HCBS only) 10-20                                                                       

  (PA-31303.5) SSI Disregard Worksheet (IL and HCBS Only)  7-17

   

  ES-3104.5      

  Determination of Need (Medical Assistance) 4-21   

  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 Eligibilies and Other Protected Medical Groups 1-21             

  Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 10-20

  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 1-21                     

  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 1-21            

  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 4-21                  

  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

   

  ES-3168

  Prepaid Funeral Agreement 12-16

  Prepaid Funeral Agreement 7-21