Note: To accommodate people with disabilities, auxiliary aides, services and modifications to policies will be provided on request. Please call Robert Stevens, KanCare Ombudsman Specialist, at 785-296-1492 or 711 (Relay) to make request at least five working days prior to training session.
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Authorization for Release of Protected Health Information: for an individual to get release of information for organizations, providers, or a class of persons (like a targeted case manager or care coordinator). The person or organization listed on line 1 and/or line 2 does not act on behalf of the member. The person or organization listed on line 1 and/or line 2 cannot request services for the beneficiary.
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Medical Representative Form: for persons on Medicaid to authorize (allow) another person to help them with medical calls, paperwork, turn in your renewal each year, use your medical card for you, etc. If the person assisting is a DPOA or Guardian, the do not need to complete the Medical Representative form in order to act on behalf of the individual. The Financial DPOA paperwork or Guardianship paperwork must be provided to the KanCare Clearinghouse. English Spanish
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Facilitator Authorization Form: A facilitator is a person who can help fill out an application and help with the application process. Eligibility people will be able to share information with this person. This person will get copies of letters sent to the applicant about the application. After the application is processed, the facilitator is not connected to your case. A facilitator can be someone such as a relative, neighbor, friend, medical office staff, or community organization employee. English Spanish
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Authorized Representative Designation Form for Grievances, Appeals and Fair Hearings
Authorized Representative Designation Form for Grievances, Appeals and Fair Hearings Large Print
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Submitting a Change to KanCare Clearinghouse Form: It is important to provide current income, address and household composition changes to the KanCare Clearinghouse while eligible for KanCare. English Spanish
