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Appendix
The appendix contains documents and materials that support all medical programs. Documents that were previously released to support a policy implementation have now been added to the appendix list. It is noted that some documents do not have a form number. Only documents previously assigned are listed with a form number. Documents are sorted by the purpose of the item, not by the program for which it is used.
Releases of Information
Releases of Information
| Form # | Form Name |
|---|---|
| KC-6100 | Medical Representative Authorization Form (PDF) |
| KC-6100S | Formulario de Autorización del Representante Médico (PDF) |
| KC-6200 | Facilitator Authorization Form (PDF) |
| KC-6200S | Formulario de Autorización del Facilitador (PDF) |
| KC-6110 | Authorization for Release of Protected Health Information (PDF) |
| KC-6110S | Autorización para la Divulgación de Información Protegida de Salud (PDF) |
Eligibility Processing
Eligibility Processing
| Form # | Form Name |
|---|---|
| P-1 | Medical Necessity (PDF) |
| P-4 | Kelley Blue Book User Instructions (PDF) |
| P-14 | Where to find Death Information on EATSS Records (PDF) |
| KC-1101 | Family Medical Application Eligibility Processing Instructions (PDF) |
| KC-1501 | E&D Medical Application Eligibility Processing Instructions (PDF) |
| KC-1801 | SSP Online Application Eligibility Processing Instructions (PDF) |
| KC-7011 | Resource Documentation Requirements (PDF) |
| KC-7012 | CE Dates for Aid Codes Chart (PDF) |
| KC-7014 | MAGI Building IBUs – Flow Chart (PDF) |
| KC-7015 | MAGI Individual Budget Unit (IBU) Examples (PDF) |
| KC-7016 | Applying the Income Rules for Children and Tax Dependents (PDF) |
| KC-7017 |
Transitional Medical Scenarios (PDF) |
| KC-7204 | Non-State SEHP Groups 12-25 (PDF) |
| N/A | HCBS Termination Instructions (PDF) |
Financial
Financial
| Form # | Form Name |
|---|---|
| F-8 | Kansas Medical Standards - Current (PDF) |
| T-3 | Life Estate Valuation Tables (PDF) |
| T-4 | Life Expectancy Table (PDF) |
| T-5 | Gambling Winnings - Income Budgeting Table (PDF) |
| KC-7000 | 300 Percent Income Chart (PDF) |
| KC-7004 | Countable Exempt Income Chart (PDF) |
| N/A | Acceptable Verification of Earned Income (PDF) |
Review Processing
Review Processing
| Form # | Form Name |
|---|---|
| KC-1201 | FM Pre-Populated Review Processing Instructions (PDF) |
| KC-1202 | FM SSP Reviews Processing Instructions (PDF) |
| KC-1601 | E&D Pre-populated Review Processing Instructions (PDF) |
| KC-7008 | Skipped Review Chart (PDF) |
| KC-7009 | Pre-populated Review Processing Standards (PDF) |
| KC-7017 | Transitional Medical Scenarios (PDF) |
| KC-7018 | Individuals Discontinued at Passive Review (PDF) |
| KC-7020 | Review Scenarios - Eligibility Policy Guidance (PDF) |
Worksheets
| Form # | Form name |
|---|---|
| W-4 | TOP Worksheet (2025) |
| W-4.1 | Applicant – Transfer of Property Calculator Instructions (PDF) |
| W-4.2 |
Recipient – Transfer of Property Calculator Instructions (PDF) |
| W-9 |
Transfer of Property Worksheet 7-25 (PDF) |
| W-10 |
Annuity Evaluation Worksheet (PDF) |
| W-14 |
MediKan Eligibility Worksheet |
| W-15 |
VA Potential Benefits Checklist (PDF) |
Citizenship and Alien Information
Citizenship and Alien Information
| Form # | Form Name |
|---|---|
| A-1 | Non-Citizen Qualification Chart (PDF) |
| A-10 | Systematic Alien Verification for Entitlement (Save) Handbook (PDF) |
| A-11 | INS Class of Admission Codes (PDF) |
| A-12 | Citizenship and Identity Verification for Medical Assistance (PDF) |
Applications and Additional Information
Application and Additional Information
Family Medical Applications and Materials
| Form # | Form Name |
|---|---|
| KC-1100 | Medical Assistance Application for Families with Children (PDF) |
| KC-1100S | Solicitud de Asistencia Médica para Familias con Niños (PDF) |
| KC-2100 | Families with Children Brochure (PDF) |
| KC-2100S | Asistencia Médica para Familias con Ninos (PDF) |
| KC-2110 | Helpful Hints for Families Card (PDF) |
| KC-2110S | Tarjetaq de Consejos útiles para las familias (PDF) |
Elderly and Person with Disabilities Applications and Materials
| Form # | Form Name |
|---|---|
| KC-1500 | Medical Assistance Application for the Elderly and Persons with Disabilities (PDF) |
| KC-1500S | Solicitud de Asistencia Médica para Personas Mayores de edad y Personas con Discapacidades (PDF) |
| KC-1105 | E&D Supplemental Application to the KC-1100 (PDF) |
| KC-1105S | Suplemento de la Solicitud para KC-1500S (PDF) |
| KC-2500 | Elderly and Persons with Disabilities Brochure (PDF) |
| KC-2500S | Asistencia Médica para Personas mayores de edad y Personas con discapacidades (PDF) |
| KC-2510 | Helpful Hints for E&D Card (PDF) |
| KC-2510S | Consejos útiles para la tarjeta E&D (PDF) |
Medicare Savings Applications and Materials
| Form # | Form Name |
|---|---|
| ES-3100.8 | Medicare Savings Program Application (PDF) |
| ES-3100.8S | Solicitud / Renovación Planes de Ahorro Medicare (PDF) |
| KC-2700 | Medicare Savings Program Brochure (PDF) |
| KC-2700S | Folleto del Programa de Ahorros de Medicare (PDF) |
Other Applications
| Form # | Form Name |
|---|---|
| ES-3100.1a | Correctional Facility Inmate- Qualifying Event (PDF) |
| ES-3100.3 | Certification of Need for Tuberculosis Treatment (PDF) |
| ES-3100.7 | Application for Medical Coverage – BCC (PDF) |
Other Information
These are to be used with a Clearinghouse Slip sheet for mailing purposes
| Form # | Form Name |
|---|---|
| M-6 | Medicaid Application Signature Page (PDF) |
| M-6S | Medicaid Application Signature Page- Spanish (PDF) |
| M-7 | Cover Letter for Unsigned Applications (PDF) |
| M-7S | Cover Letter for Unsigned Applications- Spanish (PDF) |
| M-8 | Cover Letter for Unacceptable Signature (PDF) |
| M-8S | Cover Letter for Unacceptable Signature - Spanish (PDF) |
Miscellaneous
| FORM # | FORM NAME |
|---|---|
| KC-5700 | Rights and Responsibilities - English (PDF) |
| KC-5700S | Rights and Responsibilities - Spanish (PDF) |
| KC-7203 | Voter Registration Companion Letter - English (PDF) |
| KC-7203S | Voter Registration Companion Letter - Spanish (PDF) |
| State of KS Voter Registration Form (PDF) | |
| Language Assistance Services (PDF) | |
| Document Upload Portal User Manual (PDF) |
Charts
Charts
| Form # | Form Name |
|---|---|
| KC-6001 | Administrative Roles Chart (PDF) |
| KC-7005 | SSI Payment Status Codes (PDF) |
| KC-7006 | Eligibility Actions Following SSI Termination Chart (PDF) |
| KC-7021 | Extended Postpartum (PP) CE Examples Chart (PDF) |
| KC-7022 | Reported Address Change Verification Chart (PDF) |
Archive
| Miscellaneous end-dated material |
|---|
| Returned Mail Flow Chart - Attachment 23-03-02 (PDF) |
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