Provider Forms

KDADS General Forms

FileTypeSizeUploaded onDownload
Generic Business Associate Agreement FormDOCX70.09 KB24 Feb, 2016 Download
KDADS Business Associate Agreement FormDOCX64.83 KB18 Jun, 2018 Download
Authorization for Release of Protected Health InformationPDF135.82 KB18 Jun, 2018 Download
Designated Rep. Revocation of Appointment/Reassignment of ResponsibilitiesPDF260.65 KB24 Aug, 2017 Download
Service Taxonomy Activity/Unit Definitions, Codes, Funding SourcesPDF229.11 KB15 Feb, 2016 Download
Participant Interest InventoryDOCX63.86 KB15 Aug, 2018 Download
IDD Person-Centered Support PlanDOCX63.25 KB16 Aug, 2018 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
Authorization for Release of Protected Health InformationPDF135.82 KB19 Mar, 2018 Download
PD Crisis Consumer Evaluation Of NeedsPDF342.98 KB06 Feb, 2018 Download
FAI LOC Outcome SpanishPDF21.06 KB28 Jul, 2015 Download
FAI LOC Outcome EnglishPDF76.36 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 FillableDOCX50.96 KB07 Jul, 2015 Download

Nursing Facility Financial and Statisical Report Forms

Psychiatric Residential Treatment Facilities (PRTFs)

FileTypeSizeUploaded onDownload
Cost Report InstructionsPDF1.11 MB14 Mar, 2018 Download
Cost ReportXLS236.00 KB14 Mar, 2018 Download
Census FormXLSX53.16 KB14 Mar, 2018 Download

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 2.27.17PDF605.19 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 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
Case Manager Rules of ConductPDF105.07 KB10 Aug, 2017 Download
Case Manager Rules of ConductDOCX26.57 KB10 Aug, 2017 Download
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

Extraordinary Funding

FORMS

FileTypeSizeUploaded onDownload
Extraordinary Funding JustificationPDF19.47 KB17 Jan, 2018 Download
Audit to Cost ToolXLSX51.25 KB15 Feb, 2017 Download
Extraordinatry Funding Worksheet 1.24.17XLSX56.25 KB15 Feb, 2017 Download
Guides and Worksheets 10.03.2016PDF141.50 KB15 Feb, 2017 Download
Audit to Cost Guide 2.16.2017PDF182.85 KB15 Feb, 2017 Download
EF Coversheet and Summary PagesPDF304.05 KB15 Feb, 2017 Download

QUARTERLY REPORTS

FileTypeSizeUploaded onDownload
M2016-044 EF Quarterly ReportXLSX24.99 KB04 May, 2016 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

Older Americans Act / Senior Care Act

FileTypeSizeUploaded onDownload
Uniform Program Registration FillablePDF403.67 KB16 Apr, 2018 Download
Uniform Program Registration FillableDOCX28.69 KB20 Mar, 2018 Download
Standard Intake - V2 Fillable Effective 2.15.18DOCX32.11 KB16 Feb, 2018 Download
Standard Intake - V2 Effective 2.15.18 PDF486.81 KB16 Feb, 2018 Download
Caregiver Assessment Plan and Instructions (SS-025)PDF336.17 KB14 Dec, 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