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 - Adobe Logo
Microsoft Word File Format - Word Logo
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

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:

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

Other KDADS Forms

State Adult Care Homes Forms

Nursing Facility Financial and Statisical Report Information

Quality Review Forms

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.

Individual Pages:
File Format Form Name
Acrobat Reader Document N/A Abbreviated Uniform Assessment Instrument
Acrobat Reader Document MS Word Format ADRC Information, Referral and Assistance Form - Word version is Fillable
Acrobat Reader Document MS Word Format ADRC Options Counseling Form - Word version is Fillable
Acrobat Reader Document N/A Taxonomy - Activity Definitions, Codes, Funding Sources and Unit Definitions
Acrobat Reader Document N/A BASIS Assessment
Acrobat Reader Document N/A CARE Intake
Acrobat Reader Document N/A CARE Level I
Acrobat Reader Document N/A CARE Assessment Certificate
Acrobat Reader Document N/A CARE Authorization For Release Of Protected Health Information
Acrobat Reader Document N/A CARE Level I - 30 Day Follow-up
Acrobat Reader Document N/A CARE Level I - 90 Day Follow-up
Acrobat Reader Document N/A CareGiver Assessment Plan with Instructions (complete form)
Acrobat Reader Format MS Word Format Corrective Action Plan - (SS-046)
Acrobat Reader Format MS Word Format Customer Choice - (SS-024)
Acrobat Reader Format MS Word Format Customer Code of Conduct - (SS-043)
Acrobat Reader Format MS Word Format Customer Fee Agreement - (SS-011)
Acrobat Reader Format N/A Customer Rights and Responsibilities - (SS-012)
Acrobat Reader Document N/A Discharge Closure Reasons and Codes
Acrobat Reader Document MS Word Format Functional Assessment Instrument (FAI) Form - Word version is Fillable
Acrobat Reader Document MS Word Format FAI and UAI Release of Information Form
Acrobat Reader Document   FAI Level of Care Score Outcome Form - English
Acrobat Reader Document   FAI Level of Care Score Outcome Form - Spanish
Acrobat Reader Format MS Word Format Legal Services Reporting Form (SS-028)
Acrobat Reader Format MS Word Format Notice of Action - (KDOA 904)
Acrobat Reader Format   Notification of HCBS: Referral/Initial Eligibility/ Assessment/ Services Information - (ES-3160)
Acrobat Reader Format   Notification of Medicaid/HCBS: Changes/Updates - (ES-3161)
N/A MS Word Format OAA - Final Narrative Report - Word Format - Fillable
Acrobat Reader Format N/A OAA Service Provider Report Forms for Fiscal Year 2013 - Instructions)
N/A MS Excel Format OAA Service Provider Report Forms for Fiscal Year 2013
Acrobat Reader Format Word Document Physician/RN Statement for Customer Directed Attendant Care - (SS-051)
Acrobat Reader Document N/A Poverty Level Income Guidelines
Acrobat Reader Document Word Document Uniform Program Registration - Version 4 - Word version is Fillable
Acrobat Reader Document N/A Uniform Assessment Instrument (complete form)
Acrobat Reader Document N/A Unmet Need Service Availability Codes
Acrobat Reader Document   FAI and UAI Release of Information Form -
Acrobat Reader Document N/A Page 10 - Plan of Care
Acrobat Reader Document N/A Sliding Fee Scale - FY 2013
Acrobat Reader Document Word Document Standard Intake - Word version is Fillable
Acrobat Reader Icon N/A Extraordinary Funding Notification Form Instructions
N/A Acrobat Reader Icon Extraordinary Funding Notification Form
Acrobat Reader Icon Microsoft Word Icon Final Version Guide
Acrobat Reader Icon Microsoft Word Icon Page 1 Special Tier Request Checklist Findings
Acrobat Reader Icon Microsoft Word Icon Page 2 Summary Page
Acrobat Reader Icon Microsoft Word Icon Page 3 Equipment and Supplies
Acrobat Reader Icon Microsoft Word Icon Page 4 Direct Care Staffing Schedule
Acrobat Reader Icon Microsoft Word Icon Page 5 Wage Calculation Worksheet
Acrobat Reader Icon Microsoft Word Icon Page 6 Threshold Calculation Sheet
Acrobat Reader Icon Microsoft Word Icon Page 7 Justification-PDF Behavior Examples
Acrobat Reader Icon N/A EF Report Clean

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Page Last Updated: August 7, 2014