Miscellaneous Forms are created by agencies/divisions outside of EES and are placed in the KEESM for the convenience of staff.
11-03
Action Taken on Your Administrative Disqualification Hearing (Not Guilty)*
DOC
PDF
11-04
Action Taken on Administrative Disqualification Hearing (Guilty)*
Action Taken on Administrative Disqualification Hearing (Waiver)*
Advance Notice of Administrative Disqualification Hearing*
01-03
Waiver of Right to Administrative Disqualification Hearing
Administrative Hearing Brochure
Notice of Withdrawal of Appeal
Decision Compliance Report* (Staff will get this form if the fair hearing is reversed and staff have to take action to correct the case.)
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DD-1103
04-05
Authorization to Release Medical Information
DD-1104
07-02
Disability Determination Request - Medical Assistance Case
DD-1105
Disability Determination Data/Report
DD-1106
03-13
Medical Onset Data Verification
10-03
HealthWave 21 - Pregnancy Report Form
ADM-2000
04-03
Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice)
ADM-2000S
02-05
Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice) (Spanish)
Authorization for Release of Protected Health Information
Authorization for Release of Protected Health Information (Spanish)
Protected Health Information Disclosure Tracking Log
MS-2504
01-05
Health Insurance Premium Payment Information Form
MS-2504.1
HIPPS Change Report Form
Definitive Medical Report
MS-2126
07-07
Notification of Nursing Facility Admission/Discharge
MS-2156
10-01
Medical Review of Emergency Services for Establishing SOBRA Eligibility
Monthly Summary of Expenditures For Repatriation Cases
Monthly Case Summary Report (For Repatriation Cases)
ACF-120
12-95
U.S. Repatriate Program - Privacy Act Statement and Repayment Agreement
*EES Staff Information only.