Provider Forms

KDADS General Forms

FileTypeSizeUploaded onDownload
August 9, 2022 Service-Taxonomy-Activity---Unit-Definitions-Codes-Funding-SourcesPDF305.81 KB09 Aug, 2022 Download
Business Associate AgreementDOCX66.78 KB14 Apr, 2021 Download
IDD Person-Centered Support PlanDOCX63.25 KB14 Apr, 2021 Download
Participant Interest InventoryDOCX63.86 KB14 Apr, 2021 Download
Authorization for Release of Protected Health InformationPDF224.71 KB14 Apr, 2021 Download
Designated Rep. Revocation of Appointment/Reassignment of ResponsibilitiesPDF260.65 KB14 Apr, 2021 Download

KDHE Policy Forms ES-3160 / ES-3161

Forms found on the KanCare website are sorted by those that are strictly for internal purposes and communication and those that are sent outside of the agency. Forms have retained their original form number where applicable.

http://www.kancare.ks.gov/policies-and-reports/kdhe-eligibility-policy/forms

ADRC Provider Forms

FileTypeSizeUploaded onDownload
PD-ACE FormPDF278.83 KB05 Feb, 2024 Download
PD Crisis Exception Physician StatementPDF179.07 KB05 Feb, 2024 Download
ADRC Provisional Plan Of CareDOC75.50 KB29 Nov, 2023 Download
HCBS BI Attestation FormPDF192.12 KB14 Apr, 2021 Download
FAI LOC Outcome - SpanishPDF31.94 KB14 Apr, 2021 Download
FAI LOC Outcome - EnglishPDF94.07 KB14 Apr, 2021 Download
FAI Complete Fillable 01.02.2013 - WORDDOCX92.30 KB14 Apr, 2021 Download
FAI Complete 01.02.2013 - PDFPDF978.11 KB14 Apr, 2021 Download
ADRC Information Referral Assistance FillableDOCX30.63 KB14 Apr, 2021 Download
ADRC Information, Referral and Assistance FormPDF213.02 KB14 Apr, 2021 Download
ADRC Options Counseling FillableDOCX50.96 KB14 Apr, 2021 Download

Behavioral Health Services Forms

FileTypeSizeUploaded onDownload
WHS Admission Discharge Quick RefPDF266.96 KB31 Jan, 2024 Download
WSH Navigation Quick ReferencePDF280.82 KB07 Nov, 2023 Download
KS SUD Client Admission WorkflowPDF1.15 MB14 Aug, 2023 Download
Getting Started with WellSky Human ServicesPDF2.14 MB14 Aug, 2023 Download
Mobile Assessments User GuidePDF900.96 KB14 Aug, 2023 Download
KS SUD Client Discharge WorkflowPDF955.86 KB14 Aug, 2023 Download
KDADS Universal Packet Fillable FormPDF971.91 KB14 Apr, 2021 Download

CARE Forms

Extraordinary Funding

FORMS

FileTypeSizeUploaded onDownload
Extraordinary Funding JustificationPDF19.47 KB14 Apr, 2021 Download
Audit to Cost ToolXLSX51.25 KB14 Apr, 2021 Download
Extraordinatry Funding Worksheet 1.24.17XLSX56.25 KB14 Apr, 2021 Download
Guides and Worksheets 10.03.2016PDF141.50 KB14 Apr, 2021 Download
Audit to Cost Guide 2.16.2017PDF182.85 KB14 Apr, 2021 Download
EF Coversheet and Summary PagesPDF304.05 KB14 Apr, 2021 Download

QUARTERLY REPORTS

FileTypeSizeUploaded onDownload
M2016-044 EF Quarterly ReportXLSX24.99 KB14 Apr, 2021 Download

IDD Assessor Information

FileTypeSizeUploaded onDownload
IDD Notification and Provisional Plan of Care FormPDF1.04 MB16 Feb, 2024 Download
I/DD Medicaid Waiver Individual ChoicePDF12.42 KB14 Apr, 2021 Download
Statewide BASIS Roundtable Meeting MinutesPDF15.41 MB14 Apr, 2021 Download
BASIS Assessment Section for Screeners ClarificationsPDF193.66 KB14 Apr, 2021 Download
BASIS Medical Conditions DefPDF379.55 KB14 Apr, 2021 Download
General Guidelines for BASIS AssessorsPDF38.01 KB14 Apr, 2021 Download
Childrens AssessmentPDF20.75 KB14 Apr, 2021 Download
BASIS Manual V 60PDF253.38 KB14 Apr, 2021 Download
BASIS Assessment 12.2013PDF397.62 KB14 Apr, 2021 Download

IDD Licensure Information

These documents can be found by clicking here and expanding the "Intellectual Developmental Disabilities Licensing" list.

IDD Provider Forms

FileTypeSizeUploaded onDownload
Case Manager Rules of ConductPDF105.07 KB14 Apr, 2021 Download
Case Manager Rules of ConductDOCX26.57 KB14 Apr, 2021 Download
Complaint Tracking FormXLSX22.01 KB14 Apr, 2021 Download
I/DD System Capacity Report TemplateDOCX18.16 KB14 Apr, 2021 Download
IDD Provider Billing Guidelines UnitedPDF432.82 KB14 Apr, 2021 Download
IDD Provider Billing Guidelines AMGPDF298.08 KB14 Apr, 2021 Download
2014.02.03 Auth Day Supports WeatherPDF224.32 KB14 Apr, 2021 Download
Workflow New Provider AffiliationPDF136.94 KB14 Apr, 2021 Download
Workflow Corrective ActionPDF138.02 KB14 Apr, 2021 Download
Workflow Quality Assurance Data CollectionPDF147.18 KB14 Apr, 2021 Download
Workflow IDD Initial Access 01 16 14PDF597.71 KB14 Apr, 2021 Download

IDD TCM Documents

FileTypeSizeUploaded onDownload
TCM in Managed Care - 10.17.13PDF1.28 MB14 Apr, 2021 Download
License Application TCMPDF384.40 KB14 Apr, 2021 Download

Older Americans Act / Senior Care Act

FileTypeSizeUploaded onDownload
2024 Uniform Program RegistrationRTF644.74 KB01 Feb, 2024 Download
2024 Uniform Program Registration Pg 1 OnlyRTF581.26 KB01 Feb, 2024 Download
2024 Spanish-Uniform-Program-RegistrationPDF228.30 KB01 Feb, 2024 Download
2024 Uniform Program Registration Pg 1 OnlyPDF203.30 KB01 Feb, 2024 Download
2024 Uniform Program RegistrationPDF221.25 KB01 Feb, 2024 Download
2024 Spanish-Uniform-Program-RegistrationDOCX23.35 KB01 Feb, 2024 Download
OAA-Individual-FinancialsXLSX86.33 KB16 Nov, 2023 Download
OAA Community Focal Points 2024XLSX14.97 KB25 Sep, 2023 Download
Revised-Template-OAA-MASTER-FFY2024-Budget 07.25.23XLSX194.35 KB25 Sep, 2023 Download
OAA Capital Cost TemplateXLSX12.23 KB25 Sep, 2023 Download
AP Program Characteristics (Meal Outputs) -Nutrition for FFY2024XLSX106.10 KB25 Sep, 2023 Download
2023 Uniform Program RegistrationRTF644.13 KB30 Aug, 2023 Download
2023 Uniform Program Registration Pg 1 OnlyRTF581.10 KB30 Aug, 2023 Download
2023 Uniform Program RegistrationPDF221.22 KB30 Aug, 2023 Download
2023 Spanish-Uniform-Program-RegistrationPDF440.60 KB30 Aug, 2023 Download
2023 Uniform Program Registration Pg 1 OnlyPDF203.30 KB30 Aug, 2023 Download
ARPA Individual Financials for PSAs 07.21.23XLSX91.11 KB28 Jul, 2023 Download
OAA-TIII-Cash-request-template-05.12.23XLSX19.77 KB16 May, 2023 Download
11.22.22-Revised Template-OAA-MASTER-FFY2023-BudgetXLSX194.83 KB13 Dec, 2022 Download
KS Menu Approval Sheet Eff. 10-01-2022PDF117.46 KB29 Jul, 2022 Download
Abbreviated-Uniform-Assessment-Instrument-Effective-10.01.21PDF255.56 KB28 Apr, 2022 Download
ARPA Cash request template 04.13.2022XLSX16.77 KB13 Apr, 2022 Download
3.18.22 Revised Arpa BUDGET templateXLSX193.71 KB18 Mar, 2022 Download
3.18.22 Revised_OAA-COVID19-Consolidated-Financial-Reports_XLSX71.92 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg2 OnlyPDF131.13 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg2 OnlyRTF108.95 KB18 Mar, 2022 Download
Standard-Intake-Fillable---Effective-10.01.21DOCX35.98 KB07 Mar, 2022 Download
Master Consolidated Financials OAA TemplateXLSX72.97 KB15 Dec, 2021 Download
FFY2022-2024 OAA ARPA Semi-Annual Narrative TemplateDOCX61.49 KB14 Dec, 2021 Download
OAA Annual Final Narrative Template 2021DOCX62.43 KB14 Dec, 2021 Download
DSW, Form 200-02 (2012)DOCX17.09 KB14 Dec, 2021 Download
DSW, Form 200-02 (2012)PDF45.96 KB14 Dec, 2021 Download
SS-005 Uniform Assessment Instrument – Effective 10.01.21PDF466.30 KB24 Sep, 2021 Download
SS 025 Caregiver Assessment Plan and Instructions – Effective 10.01.21PDF630.30 KB24 Sep, 2021 Download
Discharge Closure CodesPDF41.33 KB14 Apr, 2021 Download
Nutritional Health HandoutPDF465.15 KB14 Apr, 2021 Download
Authorization for Release of Protected Health InformationPDF224.71 KB14 Apr, 2021 Download
Notice of ActionDOC58.50 KB14 Apr, 2021 Download
Notice of ActionPDF15.82 KB14 Apr, 2021 Download
Customer Fee Agreement SS-011PDF126.98 KB14 Apr, 2021 Download
Case ManagementPDF102.26 KB14 Apr, 2021 Download
Customer Service Worksheet - PDFPDF68.07 KB14 Apr, 2021 Download
Customer Service Worksheet - WordDOCX39.85 KB14 Apr, 2021 Download
Legal Services Reporting SS-028 - PDFPDF176.47 KB14 Apr, 2021 Download
SCA Physician RN - PDFPDF162.06 KB14 Apr, 2021 Download
SCA Physician RN SS-051 - WordDOCX16.18 KB14 Apr, 2021 Download
Legal Services Reporting SS-028 - WordDOC182.00 KB14 Apr, 2021 Download
Customer Code of Conduct SS-043 - WordDOC33.00 KB14 Apr, 2021 Download
SCA Customer Choice - WordDOCX41.30 KB14 Apr, 2021 Download
SCA Customer Choice - PDFPDF24.14 KB14 Apr, 2021 Download

PACE

FileTypeSizeUploaded onDownload
PACE-Participant-Disenrollment-FormPDF155.23 KB22 Nov, 2023 Download

SED Forms

FileTypeSizeUploaded onDownload
Attachment E SED Waiver Annual Evaluation of Level of Care (LOC)DOCX38.51 KB07 Apr, 2022 Download
HCBS SED Participant Interest InventoryDOCX84.26 KB14 Apr, 2021 Download
Attachment A Initial Clinical Eligibility FormPDF324.15 KB07 Jul, 2021 Download
Attachment B Request for Exception to Minimum Age CriteriaDOCX32.48 KB07 Jul, 2021 Download
SED Provisional Plan of CareDOCX17.10 KB14 Apr, 2021 Download
SED Eligibility New ProcessPDF148.66 KB14 Apr, 2021 Download
Attachment C Initial Request For Exception to Age 18 CriteriaDOCX32.50 KB07 Jul, 2021 Download
Attachment D Request for Exception to CBCL CriteriaDOCX31.18 KB07 Jul, 2021 Download

Quality Review Forms

FileTypeSizeUploaded onDownload
Case Management Entity (CME) Referral and Response Form KDADS SCC Quality Review FormPDF416.03 KB14 Apr, 2021 Download