All changes are effective Aug. 18, 2017, unless specified otherwise in the implementation memo.
These items are being removed because of the change to KEES or because KDHE has developed a separate Medical KEESM.
Appendix
C-25, Child Care Checklist
C-26, Referral for Child Care Provider Enrollment Application
C-27, EHS/Child Care Partnership Checklist
E-23, Diversion Payment Option Decision Tree
E-24, Diversion Payment Option Process Flow
M-2 thru M-7: All Medical related
P-2, Statement of Medically Necessity
P-6, Landlord Letter
P-11, Authorization for Release of PHI
R-1, Medical Subrogation Referral - Adoption
R-2, Medical Subrogation Referral - Injury
T-5, RESERVED
T-13, Under development: Review Type Matrix
W-12, Fair Labor Standard Act (FLSA) Calculation Table
W-13, Child Care Plan Hours Worksheet
W-14, MediKan Eligibility Worksheet
W-15, VA Potential Benefits Checklist
W-16, Patient Liability Worksheet
W-17, Reasonable Compatibility Tool
W-18, Under development: Review Reactivation Tool
X-5, Back of Notices of Action
X-8, ICT Checklist
X-9, Concerns About A Case Received in Transfer from XX County
Forms
Child Care Forms Explanations
CC-1626A, Child Care Provider Denial Notice
CC-1630, Legally Exempt Release of Information Child Abuse/Neglect Registry Check
ES-1100, Request for Administrative Hearing
ES-1602, Child Care Provider Rate Modification
ES-1604, Daily Attendance Record (Sample Form)
ES-1606, Request for Supervisory Approval - Child Care Exceeding 215 Per Month
ES-1627a, Request for Enhanced Rate for Special Care
ES-1640, Statement of Understanding - Employed Income Eligible Child Care Assistance
ES-3100.3, Certification of Need for Hospital Tuberculosis Treatment
ES-3100.7, Application for Medical Coverage - Breast and Cervical Cancer
ES 3104.5, Determination of Need (Medical Assistance)
ES-3104.6, Determination Worksheet for PICKLE Eligibles and Other Protected Medical Groups
ES-3105.1, Request for Information
ES-3108, Appointment of Authorized Medical Agent for a Minor
ES-3110, Negative Drug test
ES-3152, Medical Assistance Lien Physician Verification
ES-3153, Statement of Continuing Eligibility (Working Healthy)
ES-3160, Notification of Medicaid/HCBS Services Referral/Initial Eligibility/Assessment/ Services Information
ES-3161, Notification of Medicaid/HCBS/Working Healthy Services
ES-3162, Resource Assessment and Allowance Determination Form
ES-3163, Income Allowance Determination Form
ES-3165, Working Healthy and Premium Information
ES-3166, Notification of PACE Information
ES-3167, Annuities and the Kansas Medical Assistance Program Information for Medicaid Applicants and Recipients
ES-3167A, Annuity Information Request
ES-3168, Prepaid Funeral Agreement
ES-3169, Irrevocable Assignment of Benefits of Life Insurance/Annuity Policy
ES-3170, Beneficiary/Patient Spenddown Billed Form
ES-3171, Irrevocable Collateral Assignment of Life Insurance Proceeds
ES-3178, Authorization Form for the Release of Information
ES-3820, Notice of Eligibility Review
ES-3822, Notice of Review - Medical Assistance - BCC Program
ES-3822A, Statement of Continuing Cancer Treatment Medical Assistance - BCC Program
ES-3901, Presumptive Medical Disability Team Referral
ES-3903, KDHE Presumptive Medical Disability Determination Questionnaire
ES-3904, HIPAA Compliant Authorization to Release Information to KDHE
ES-3906, Presumptive Medicaid Disability Determination Notification of Changes and Final Decision Form
ES-3907, Disability Review Team Referral
ES-3909, Applicant Instructions for The Presumptive Medical Disability Process
ES-4103, School Enrollment Verification
ES-4109, Referral for Non-Cooperation with a Fraud Investigation
ES-4306, Employer Contact Record
ES-4306F, Food Assistance Employer Contact Record (For Food Assistance Potential Employment Violation Only)
ES-4307, Penalty Tracking Sheet
ES-4312, ABAWD Eligibility Tracking Form
IM-3105.5, Request for Medical Expense Information
IM-3121, VA-DCF Information System
PA-3103.5, MAcrSSI Disregard Worksheet (Independent Living and HCBS Only)
Miscellaneous
Disability Determination forms DD-1103, DD-1104, DD-1105, DD-1106
Authorization for Release of Protected Health Information, English and Spanish
Protected Health Information Disclosure Tracking Log
MS-2504, Health Insurance Premium Payment Information Form
MS-2504.1, HIPPS Change Report Form
MS-2156, Medical Review of Emergency Services for Establishing SOBRA Eligibility
This change was coordinated with staff in Economic and Employment Services, Executive leadership, and the EES Program Administrators.