Information For:

Provider Site Home Page

Provider Related Forms

Complaint Reporting

• Elder Abuse Hotlines
• Facility Complaint Investigation Report Form (PDF) - Updated 01/31/2012
• Facility Complaint Investigation Report Form (Word) - Updated 01/31/2012
• 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@aging.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
• 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

• Annual Reporting Worksheets and Forms
• Adult Care Home Statistics Report Forms and Web Application

TCM Forms

• Targeted Case Management (TCM) Forms

SCA Forms

• Senior Care Act (SCA) Forms

OAA Forms

• Older Americans Act (OAA) Forms

Quality Review Forms

• Case Management Entity (CME) Referral and Response Form
  KDOA LCE Quality Review Form

Assessment Forms

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
	N/A	Standard Intake
	N/A	Uniform Program Registration
	N/A	Abbreviated Uniform Assessment Instrument
	N/A	Uniform Assessment Instrument (complete form) - - Updated Page 9b (ESD Worksheet) 07/01/2011
	N/A	Page 10 - Plan of Care
	N/A	Care Intake
	N/A	Care Level I
	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)
	N/A	CareGiver Assessment Plan Page 1
	N/A	CareGiver Assessment Plan Page 2

Other KDOA Forms

File Format		Form Name
	N/A	Discharge Closure Reasons and Codes - Revised 07/2010
	N/A	Poverty Level Income Guidelines - Revised 04/2011
	N/A	Aging Taxonomy - Activity Definitions, Codes, Funding Sources and Unit Definitions - Revised 01/2011
	N/A	Sliding Fee Scale - FY 2012
		Web Application System Change Request Form
		Web Application Report Request Form

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