• KDADS Public Website
• Kansas.gov

Provider Related Forms

NOTICE REGARDING FORMS:

1. All forms have been changed to reflect KDADS, however you may need to refresh your screen (F5 on the keyboard) to display these changes.
2. The form number at the bottom of the pages will still reflect "KDOA-..." This is as intended by the agency.

Adobe Acrobat File Format -
Microsoft Word File Format -
Format Not Available at this time - NA

All the below listed forms are in Acrobat Reader Format. This format will enable the documents to be printed only. The forms would be for manual completion.

Complaint Reporting

• Elder Abuse Hotlines
• Facility Complaint Investigation Report Form (PDF)
• Facility Complaint Investigation Report Form (Word)
• ANE Witness Form (PDF)
• ANE Witness Form (Word)

Reporting Reasonable Suspicion of a Crime

Facilities or covered individuals needing to report a suspected crime against a resident when the hotline is closed may submit an e-mail to suspectedcrime@kdads.ks.gov with the following information:

• Persons involved (resident victim, alleged perpetrator, witnesses, covered individuals with reason to suspect a crime has occurred)
• Date and time of the incident
• Description of the incident
• Injury, if any, to the resident
• Date and time report made to law enforcement
• Law Enforcement agency and case number

Complaint Program staff will respond to the e-mails during regular hotline hours.

State Adult Care Homes Forms

• State Adult Care Homes Licensure Forms
• Psychiatric Residential Treatment Facility (PRTF) Forms
• Administrator/Operator and Facility Change Forms
• Medicaid Enrollment Forms
• Medicaid Provider - New Enrollment and Change of Ownership Forms
• Medicare Certification Forms
• Medical Care Facilities - Responsibility of Kansas Department of Health and Environment

Nursing Facility Financial and Statisical Report Information

• Nursing Facility Financial and Statistical Worksheets
• Annual Reporting Worksheets and Forms
• Adult Care Home Statistics Report Forms and Web Application

HCBS Provider Form

• HCBS Provider Forms

Quality Review Forms

• Case Management Entity (CME) Referral and Response Form
  KDADS SCC Quality Review Form

Forms - All Program Types

All the below listed forms are in Acrobat Reader Format. This format will enable the documents to be printed only. The forms would be for manual completion.

File Format		Form Name
	N/A	Abbreviated Uniform Assessment Instrument
		ADRC Information, Referral and Assistance Form - Word version is Fillable
		ADRC Options Counseling Form - Word version is Fillable
	N/A	Taxonomy - Activity Definitions, Codes, Funding Sources and Unit Definitions
	N/A	CARE Intake
	N/A	CARE Level I
	N/A	CARE Assessment Certificate
	N/A	CARE Authorization For Release Of Protected Health Information
	N/A	CARE Level I - 30 Day Follow-up
	N/A	CARE Level I - 90 Day Follow-up
	N/A	CareGiver Assessment Plan with Instructions (complete form)
		Corrective Action Plan - (SS-046)
		Customer Choice - (SS-024)
		Customer Code of Conduct - (SS-043)
		Customer Fee Agreement - (SS-011)
	N/A	Customer Rights and Responsibilities - (SS-012)
	N/A	Discharge Closure Reasons and Codes
		Functional Assessment Instrument (FAI) Form - Word version is Fillable
		FAI Release of Information Form - Updated 04/15/2013
		FAI Level of Care Score Outcome Form - English
		FAI Level of Care Score Outcome Form - Spanish
		Legal Services Reporting Form (SS-028)
		Notice of Action - (KDOA 904)
		Notification of HCBS: Referral/Initial Eligibility/ Assessment/ Services Information - (ES-3160)
		Notification of Medicaid/HCBS: Changes/Updates - (ES-3161)
N/A		OAA - Final Narrative Report - Word Format - Fillable
	N/A	OAA Service Provider Report Forms for Fiscal Year 2012 - Instructions
N/A		OAA Service Provider Report Forms for Fiscal Year 2012 - Forms in Excel Format
	N/A	Physician/RN Statement for Customer Directed Attendant Care - (SS-051)
	N/A	Poverty Level Income Guidelines
	N/A	Uniform Program Registration
	N/A	Uniform Assessment Instrument (complete form)
		UAI Release of Information Form - Updated 04/15/2013
	N/A	Page 10 - Plan of Care
	N/A	Sliding Fee Scale - FY 2013
	N/A	Standard Intake
		Web Application System Change Request Form
		Web Application Report Request Form
	N/A	Web Application System Change and Report Request Packet - includes instructions and samples

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