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
F-8
Kansas Medical Standards 1-21
Kansas Medical Standards 7-20
Kansas Medical Standards 4-20
T-3
Life Estate Valuation Tables
T-4
Life Expectancy Table 8-18
T-5
Gambling Winnings - Income Budgeting Table
N/a
Reasonable Compatibility Tool
Acceptable Verification of Earned Income 7-15
KC-7000
300 Percent Income Chart 1-21
300 Percent Income Chart 1-20
KC-7004
Countable Exempt Income Chart 11-20
Countable Exempt Income Chart 7-18
P-1
Medical Necessity
P-4
Kelley Blue Book User Instructions
P-14
Where to find Death Information on EATSS Records
KC-1100-JA
Family Medical Processing Eligibility Job Aid
KC-1500-JA
E&D Medical Processing Eligibility Job Aid
KC-1800-JA
SSP Application Job Aid 3-20
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
HCBS Termination Instructions
Agency Cross Communication Guide
KC-7016
Applying the Income Rules for Children and Tax Dependents
Form # Form Name
KC-1201 Family Medical Pre-Populated Review Form Instructions
KC-1601 E&D Pre-Populated Review Form 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-7019 Medically Needy Late Review Guide
KC-7020 Review Scenarios - Eligibility Policy Guidance
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
W-10
Annuity Evaluation Worksheet
W-14
MediKan Eligibility Worksheet
W-15
VA Potential Benefits Checklist
W-16
Patient Liability Worksheet
A-1
Immigrant status/Program Qualification chart
A-10
Systematic Alien Verification for Entitlements (SAVE) Handbook
A-11
INS Class of Admission Codes
A-12
Citizenship and Identify Verification for Medical Assistance and General Assistance
Family Medical
KC-1100 Medical Assistance Application for Families with Children
KC-1100S Solicitud de Asistencia Médica para Familias con Niños (Application for Families with Children- Spanish)
KC-2100 Families with Children Brochure
KC-2100S Asistencia Médica para Familias con Ninos (Families with Children Brochure – Spanish)
KC-2110 Helpful Hints for Families
KC-2110S Consejos útiles para las familias (Helpful Hints for Families – Spanish)
Elderly and Person with Disabilities
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
(Medical Assistance Application for E&D– Spanish)
KC-1105 E&D Supplement to the KC-1100
KC-1105S Suplemento de la Solicitud para KC-1100S (E&D Supplement to the KC-1000-Spanish)
KC-2500 Elderly and Persons with Disabilities brochure
KC-2510 Helpful Hints for E&D
KC-2510S Consejos útiles para Ancianos y Discapacitados (Helpful Hints for E&D- Spanish)
Medicare Savings Applications
ES-3100.8 Medicare Savings Program application
ES-3100.8S Solicitud / Renovación Planes de Ahorro Medicare (MSP application- Spanish)
KC-2700 Medicare Savings Program Brochure
KC-2700S Programas de Ahorro de Medicare (Medicare Savings Program Brochure-SP)
Other Applications
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
M-6 Medicaid Application Signature Page
M-7 Cover Letter for Unsigned Applications
M-8 Cover Letter for Unacceptable Signature
Language Assistance Services
OAH Frequently Asked Questions
PRTF List
KC-5700 Rights and Responsibilities English
KC-5700S Rights and Responsibilities - Spanish
User access for KEESM SSP Portal
State of KS Voter registration form (online link)
KC-7203 Voter Registration Instructions Cover
KC-7203S Voter Registration Instructions Cover Spanish
KC-6001
Administrative Roles Chart
Countable Exempt Income Chart
KC-7005
SSI Payment Status Codes
KC-7006
Eligibility Actions Following SSI Termination Chart
KC-7007
Standard Medical Aid Code Labels
KC-7010
Medical Hierarchy Chart
KC-7200
Document Types and Definitions Used for Imaging on Medical Cases
Kansas Medical Standards 1-20
Kansas Medical Standards 9-19 corrected
Kansas Medical Standards 7-19 (obsolete)
Kansas Medical Standards 4-19 corrected
Kansas Medical Standards 4-19 (obsolete)
Kansas Medical Standards 1-19
Kansas Medical Standards 7-18
Kansas Medical Standards 4-18
Kansas Medical Standards 1-18
Kansas Medical Standards 4-17
Kansas Medical Standards 5-16
Kansas Medical Standards 7-15
Kansas Medical Standards 4-15
Kansas Medical Standards 1-15
300 Percent Income Chart 10-19
300 Percent Income Chart 1-19
300 Percent Income Chart 4-18
300 Percent Income Chart 7-17
300 Percent Income Chart 4-15
Medical Necessity 7-19
Medical Necessity 7-17
Life Estate Valuation 8-18
Life Estate Valuation 7-17
Life Expectancy Tables 8-18
Life Expectancy Tables 7-09
Life Expectancy Tables 5-07
Transfer of Property Worksheet 7-20
Transfer of Property Worksheet 7-19
Transfer of Property Worksheet 7-18
Transfer of Property Worksheet 7-17