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 4-24
ES-3165S Working Healthy Premiums – Spanish 4-24
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
KC-4501 Facility Birth Reporting form for Medicaid Deemed Newborns
KC-4510 Tax Information and Relationship (TIAR) form
Also available in KEES as V777 in both English and Spanish.
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
State Fair Hearing forms
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
INTERNAL
ES-3103.5
SSI Disregard Worksheet (IL and HCBS only) 7-21
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) 4-23
Determination of Need (Medical Assistance) 4-22
Determination of Need (Medical Assistance) 7-21
Determination of Need (Medical Assistance) 4-21
Determination of Need (Medical Assistance) 4-20
Determination of Need (Medical Assistance) 9-19
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 1-24
Determination Worksheet for Pickle Eligibiles and other Protected Medical Groups 1-23
Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups 1-22
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
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
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 1-24
Resource Assessment Allowance Determination 1-23
Resource Assessment Allowance Determination 1-22
Resource Assessment Allowance Determination 1-21
Resource Assessment Allowance Determination 1-20
Resource Assessment Allowance Determination 7-19 (1-19 corrected) X
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 1-24
Income Allowance Determination Form 7-23
Income Allowance Determination Form 1-23
Income Allowance Determination Form 7-22
Income Allowance Determination Form 1-22
Income Allowance Determination Form 7-21
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
EXTERNAL
ES-3165
Working Healthy and Premium Information 04-24
Working Healthy and Premium Information 05-23
Working Healthy and Premium Information 4-23
Working Healthy and Premium Information 4-22
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