Provider Forms

KDADS General Forms

ADRC Provider Forms

FileTypeSizeUploaded onDownload
FAI LOC Outcome SpanishPDF21.06 KB28 Jul, 2015 Download
FAI LOC Outcome EnglishPDF76.36 KB28 Jul, 2015 Download
FAI/UAI Release Of Information - 01.2015PDF172.00 KB28 Jul, 2015 Download
FAI Complete 01.02.2013 - PDFPDF978.11 KB28 Jul, 2015 Download
FAI Complete Fillable 01.02.2013 - WORDDOCX92.30 KB28 Jul, 2015 Download
ADRC Information, Referral and Assistance FormPDF213.02 KB07 Jul, 2015 Download
ADRC Information Referral Assistance FillableDOCX30.63 KB07 Jul, 2015 Download
ADRC Options Counseling FormPDF114.33 KB07 Jul, 2015 Download
ADRC Options Counseling FillableDOCX50.96 KB07 Jul, 2015 Download

Adult Care Homes

CARE Forms

FMS

FileTypeSizeUploaded onDownload
FMS FY16 Provider AgreementDOCX47.99 KB08 Apr, 2016 Download
FMS Provider Agreement FY16DOCX44.62 KB08 Mar, 2016 Download
HCBS-TA waiver PSA Checklist rev.11.2015DOC64.00 KB31 Dec, 2015 Download
FMS Provider Agreement FY16 REVISED FINAL 12-23-15DOCX44.19 KB28 Dec, 2015 Download
FMS manual final 12.28.2015PDF605.19 KB28 Dec, 2015 Download
FMS Provider Agreement January 2016DOCX53.81 KB10 Dec, 2015 Download
2015-11-30 FMS Q and APDF129.39 KB09 Dec, 2015 Download
KDADS FMS MEMORANDUM OF CLARIFICATION FMS AGENT - January 22, 2015PDF30.31 KB07 Jul, 2015 Download
Return of Excess Funds Transmittal and Certification - 2015PDF35.56 KB16 Jun, 2015 Download
Return of Excess Funds Transmittal and Certification - 2015PDF35.56 KB10 Jun, 2015 Download
Return of Excess Funds Affirmation - No Excess Funds - 2015PDF35.38 KB10 Jun, 2015 Download
FMS Manual - April 10, 2015PDF1.61 MB09 Jun, 2015 Download

IDD Assessor Information

FileTypeSizeUploaded onDownload
Statewide BASIS Roundtable Meeting MinutesPDF15.41 MB15 Feb, 2017 Download
BASIS Assessment Section for Screeners ClarificationsPDF193.66 KB15 Feb, 2017 Download
BASIS Medical Conditions DefPDF379.55 KB09 Jun, 2015 Download
General Guidelines for BASIS AssessorsPDF38.01 KB09 Jun, 2015 Download
Childrens AssessmentPDF20.75 KB09 Jun, 2015 Download
BASIS Manual V 60PDF253.38 KB09 Jun, 2015 Download
BASIS Assessment 12.2013PDF397.62 KB16 Mar, 2015 Download

IDD Extraordinary Funding

Instructions for completing an EF request on the new forms:

Please note, you will have to have pop-ups enabled for the kdads.ks.gov site.

It is helpful to have the most recent version of adobe reader installed on your computer; go to www.adobe.com/downloads/updates.html (scroll to Adobe Acrobat reader and select your operating system), click on the icon next to “looking for the most recent version?”. Follow steps.

Go to: http://www.kdads.ks.gov/provider-home/forms

  1. Scroll down to:IDD Extraordinary Funding
  2. Click on the PDF icon next to “Extraordinary Funding Request Form”
  3. Complete fields
  4. To attach documents:
    1. Click on “add attachments” button, a pop-up window should open, go to the folder in which you have the document you wish to attach, double click.
    2. OR click on the paperclip to the left of the screen (below the page thumbnails icon, or above the binoculars for search) and click on the tiny paperclip with the yellow star, a pop-up window should open, go to the folder in which you have the documents you wish to attach, double click.
    3. Please note, the paperclip icon on the left side of the page is also where you can see what documents you have attached to this request.
  5. To save a copy of the completed form to your own computer, please click on the floppy disc icon on the left top of the screen, follow the steps.
  6. Attach saved document to an encrypted e-mail and send to the appropriate MCO.

If you are still experiencing problems with the form, please make sure that the browser you are using is updated and compatible with the KDADS website.

FileTypeSizeUploaded onDownload
Extraordinary Funding Request FormPDF2.01 MB03 Nov, 2015 Download
Extraordinary Funding RequestDOCX421.58 KB05 Dec, 2016 Download
Complete GuidePDF103.91 KB01 Dec, 2015 Download
EF Justification FormPDF19.46 KB31 Aug, 2016 Download
Audit To Cost Tool_091316XLSX35.22 KB16 Sep, 2016 Download
Extraordinary Funding Worksheet_091316XLSX49.41 KB16 Sep, 2016 Download

IDD Licensure Information

FileTypeSizeUploaded onDownload
DD DNR guidancePDF69.14 KB24 Jun, 2016 Download
Licensure Packet InstructionsPDF286.98 KB09 Jun, 2015 Download
New CSP suggestions for a Business Plan 3.16.15PDF343.16 KB16 Mar, 2015 Download
Full TCM License Checklist 3.16.15PDF153.64 KB16 Mar, 2015 Download
Limited License Checklist 3.16.15PDF401.26 KB16 Mar, 2015 Download
Limited Scope Application 3.16.15PDF116.18 KB16 Mar, 2015 Download
IDD Day Res license application 9.8.2014PDF413.81 KB16 Mar, 2015 Download

IDD Provider Forms

FileTypeSizeUploaded onDownload
Complaint Tracking FormXLSX22.01 KB26 Jul, 2016 Download
I/DD System Capacity Report TemplateDOCX18.16 KB26 Jul, 2016 Download
IDD Provider Billing Guidelines UnitedPDF432.82 KB09 Jun, 2015 Download
IDD Provider Billing Guidelines SunflowerPDF649.34 KB09 Jun, 2015 Download
IDD Provider Billing Guidelines AMGPDF298.08 KB09 Jun, 2015 Download
2014.02.03 Auth Day Supports WeatherPDF224.32 KB09 Jun, 2015 Download
Workflow New Provider AffiliationPDF136.94 KB08 Jun, 2015 Download
Workflow Corrective ActionPDF138.02 KB08 Jun, 2015 Download
Workflow Quality Assurance Data CollectionPDF147.18 KB08 Jun, 2015 Download
Workflow IDD Initial Access 01 16 14PDF597.71 KB08 Jun, 2015 Download
CDDO Notification Form - Fillable - 5.20.14DOCX99.70 KB16 Mar, 2015 Download
Death Report Workflow Process - 12.27.13PDF110.57 KB16 Jan, 2015 Download

IDD TCM Documents

FileTypeSizeUploaded onDownload
TCM in Managed Care - 10.17.13PDF1.28 MB23 Jun, 2015 Download
License Application TCMPDF384.40 KB09 Jun, 2015 Download

Nursing Facility Financial and Statisical Report Forms

Older Americans Act / Senior Care Act

FileTypeSizeUploaded onDownload
Uniform Program Registration FillableDOCX34.58 KB28 Mar, 2016 Download
Uniform Program RegistrationPDF139.11 KB28 Mar, 2016 Download
Caregiver Assessment Plan and Instructions (SS-025)PDF336.17 KB14 Dec, 2015 Download
Standard IntakePDF549.55 KB24 Nov, 2015 Download
Standard Intake - FillableDOCX40.68 KB24 Nov, 2015 Download
SS-005 Uniform Assessment InstrumentPDF522.12 KB19 Nov, 2015 Download
Notice of ActionDOC58.50 KB18 Nov, 2015 Download
Notice of ActionPDF15.82 KB18 Nov, 2015 Download
Customer Fee Agreement SS-011DOC32.00 KB03 Nov, 2015 Download
Customer Fee Agreement SS-011PDF126.98 KB03 Nov, 2015 Download
Case ManagementPDF102.26 KB02 Oct, 2015 Download
Customer Service Worksheet - PDFPDF68.07 KB01 Oct, 2015 Download
Customer Service Worksheet - WordDOCX39.85 KB01 Oct, 2015 Download
SCA Physician RN SS-051 - WordDOCX16.18 KB30 Jul, 2015 Download
SCA Physician RN - PDFPDF162.06 KB30 Jul, 2015 Download
Legal Services Reporting SS-028 - PDFPDF176.47 KB30 Jul, 2015 Download
Final Narrative Report - 2012DOC35.00 KB30 Jul, 2015 Download
OAA Manual Report FormsXLSX43.16 KB30 Jul, 2015 Download
Legal Services Reporting SS-028 - WordDOC182.00 KB30 Jul, 2015 Download
OAA Manual Report InstructionsPDF152.71 KB30 Jul, 2015 Download
SCA Corrective Action Plan SS-046 - PDFPDF49.59 KB30 Jul, 2015 Download
SCA Corrective Action Plan SS-046 - WordDOC33.50 KB30 Jul, 2015 Download
SCA Customer Choice - PDFPDF24.14 KB30 Jul, 2015 Download
SCA Customer Choice - WordDOCX41.30 KB30 Jul, 2015 Download
Customer Code of Conduct SS-043 - WordDOC33.00 KB30 Jul, 2015 Download
Discharge Closure CodesPDF50.86 KB30 Jul, 2015 Download
Consumer Rights and Responsibilities SS-012PDF55.62 KB30 Jul, 2015 Download
Customer Code of Conduct SS-043 - PDFPDF65.47 KB30 Jul, 2015 Download
Abbreviated Uniform Assessment InstrumentPDF193.53 KB07 Jul, 2015 Download

Quality Review Forms

FileTypeSizeUploaded onDownload
Case Management Entity (CME) Referral and Response Form KDADS SCC Quality Review FormPDF416.03 KB23 Jul, 2015 Download