Provider Forms

KDADS General Forms

FileTypeSizeUploaded onDownload
Service Taxonomy Activity - Unit Definitions, Codes, Funding SourcesPDF288.94 KB27 Sep, 2021 Download
PD Crisis Exception; Physician Statement FormPDF202.74 KB24 Sep, 2021 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
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
PD Crisis Consumer Evaluation Of NeedsPDF342.98 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
KDADS Universal Packet Fillable FormPDF971.91 KB14 Apr, 2021 Download

Nursing Facility Financial and Statisical Report Forms

Psychiatric Residential Treatment Facilities (PRTFs)

FileTypeSizeUploaded onDownload
Cost Report InstructionsPDF125.83 KB14 Apr, 2021 Download
Cost ReportXLS236.00 KB14 Apr, 2021 Download
Census FormXLSX53.16 KB14 Apr, 2021 Download

CARE Forms

SED Forms

FileTypeSizeUploaded onDownload
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 A Initial Clinical Eligibility FormPDF230.36 KB14 Apr, 2021 Download
Attachment A Initial Clinical Eligibility FormDOCX46.85 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
Attachment E SED Waiver Annual Evaluation of Level of Care (LOC)DOCX37.54 KB07 Jul, 2021 Download
Attachment F SED Provisional Plan of CareDOCX30.49 KB07 Jul, 2021 Download

IDD Assessor Information

FileTypeSizeUploaded onDownload
IDD Notification and Provisional Plan of Care FormPDF141.08 KB14 Apr, 2021 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
CDDO Notification Form - Fillable - 5.20.14DOCX99.70 KB14 Apr, 2021 Download
Death Report Workflow Process - 12.27.13PDF110.57 KB14 Apr, 2021 Download

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 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
SS-005 Uniform Assessment Instrument – Effective 10.01.21PDF466.30 KB24 Sep, 2021 Download
Abbreviated Uniform Assessment Instrument – Effective 10.01.21PDF207.70 KB24 Sep, 2021 Download
Uniform Program Registration – Effective 10.01.2021PDF203.74 KB24 Sep, 2021 Download
SS 025 Caregiver Assessment Plan and Instructions – Effective 10.01.21PDF630.30 KB24 Sep, 2021 Download
Uniform Program Registration – Effective 10.01.2021DOCX17.19 KB24 Sep, 2021 Download
Standard Intake Fillable - Effective 10.01.21DOCX35.94 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
SCA Corrective Action Plan SS-046 - WordDOC33.50 KB14 Apr, 2021 Download
SCA Corrective Action Plan SS-046 - PDFPDF49.59 KB14 Apr, 2021 Download
Customer Code of Conduct SS-043 - PDFPDF65.47 KB14 Apr, 2021 Download
Consumer Rights and Responsibilities SS-012PDF55.62 KB14 Apr, 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