Provider Forms

KDADS General Forms

FileTypeSizeUploaded onDownload
Service Taxonomy Activity - Unit Definitions, Codes, Funding SourcesPDF297.09 KB10 Feb, 2022 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

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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 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

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

Nursing Facility Financial and Statistical Report Forms

Older Americans Act / Senior Care Act

FileTypeSizeUploaded onDownload
4.7.2022 Revised OAA MASTER FFY2022 budget templateXLSM205.47 KB27 Jun, 2022 Download
Spanish-Uniform-Program-RegistrationPDF391.59 KB29 Apr, 2022 Download
Abbreviated-Uniform-Assessment-Instrument-Effective-10.01.21PDF255.56 KB28 Apr, 2022 Download
OAA TIII Cash request template 04.13.2022XLSX15.40 KB13 Apr, 2022 Download
ARPA Cash request template 04.13.2022XLSX16.77 KB13 Apr, 2022 Download
FFY2022-ARPA-Individual-FinancialsXLSX86.76 KB11 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 RegistrationPDF220.98 KB18 Mar, 2022 Download
2022 Uniform Program RegistrationRTF645.93 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg2 OnlyPDF131.13 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg1 OnlyPDF199.91 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg2 OnlyRTF108.95 KB18 Mar, 2022 Download
2022 Uniform Program Registration Pg 1 OnlyRTF583.03 KB18 Mar, 2022 Download
Capital Cost Justification FFY2020-2021XLSX16.64 KB07 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
FFY2022 OAA Individual FinancialsXLSX86.80 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
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

PACE

FileTypeSizeUploaded onDownload
PACE Participant Disenrollment FormPDF102.53 KB15 Jun, 2022 Download

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

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