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Non-KEES Forms
Notices
KEES Website Notices
- M802 POTENTIAL SPENDDOWN INFORMATION NOTICE
- M834 MA NOTICE OF REPAYMENT
- M836 N836 SPENDDOWN INFORMATION NOTICE
- M837 MA-MEDICAL CARD RETURNED
- N744 WORKING HEALTHY - UMEMPLOYMENT PLAN REQUEST
- N810 WORKING HEALTHY PREMIUM INFORMATION
- N812 WORKING HEALTHY DESK REVIEW
- N832 MEDICAL ASSISTANCE PENDING SSA DECISION
- N838 S838 TERMINATION/DECERTIFICATION ACH FACILITY
- N839 S839 TRANSFER TO ANOTHER NURSING FACILITY
- P408 GENERAL NOTICE OF DISCONTINUANCE
- P600 MP - REINSTATE AFTER SUSPENSION
- P700 MP CHANGE GENERAL
- P803 MP - REPORTING REQUIREMENTS
- POSTMASTER LETTER
- V000 GENERAL VERIFICATION REQUEST
- V001 SCHOOL VERIFICATION REQUEST
- V003 REQUEST FOR EMPLOYMENT INFORMATION
- V005 HEALTH INSURANCE INFORMATION REQUEST
- V006 UNREPORTED INCOME VERIFICATION REQUEST
- V012 INCOMPLETE CHANGE-NEW HOUSEHOLD MEMBER
- V015 POTENTIAL BENEFITS REQUEST
- V025 GENERAL PENDING NOTICE
- V027 ASSESSMENT OF RESOURCES-SPOUSAL IMPOV.
- V032 MEDICAL DETERMINATION PENDING
- V070 ID & CITIZENSHIP VERIFICATION REQUEST
- V075 REQ - AUTH FOR MEDICAL AGENT FOR MINOR
- V080 SSPP REPLACEMENT
- V082 SSPP DIRECT DEPOSIT REQUEST
- V100 APPROVAL LTC-SPOUSAL IMPOV. INFORMATION
- V116 CONDITIONAL ELIGIBILITY APPROVAL
- V117 SSPP APPROVAL
- V118 SSPP APPROVAL WITH DD
- V200 LTC DENIAL-RESOURCES EXCEED SP IM LMT
- V304 FUNERAL AGREEMENT INFO
- V400 BURIAL ASSISTANCE APPROVAL
- V408 SSPP CLOSURE
- V498 CLOSURE - OTHER REASONS
- V600 CERTIFICATE OF CREDITABLE COVERAGE
- V601 SPOUSAL ELECTIVE SHARE REQUEST
- V801 CASE TRANSFER NOTICE
- V828 REPAYMENT AGREEMENT REMINDER
- V830 DEMAND NOTICE AT CLOSURE
- X019 REPORTING THE BIRTH OF YOUR CHILD
KEES Website Notices Facility Notice
- N911 FACILITY NOTICE APPROVAL ACH ONE MONTH
- N912 FACILITY NOTICE APPROVAL ACH TWO MONTHS
- N913 FACILITY NOTICE APPROVAL ACH THREE MONTHS
- NOTICE: S921 SI - FACILITY - GENERAL DENIAL
- C941 N941 S941 FACILITY NOTICE GENERAL CLOSURE
- C971 N971 S971 – FACILITY NOTICE MASS CHANGE
- C972 N972 S972 FACILITY NOTICE CHANGE IN PATIENT LIABILITY
- C973 N973 S973 FACILITY NOTICE SUSPENSION LTC PAYMENT
- N974 FACILITY NOTICE REVIEW COMPLETE REMAINS ELIGIBLE
- N978 FFACILITY NOTICE EXCESS LIABILITY NO SPENDOWN SPENDOWN MET
- C979 TITLE: FACILITY-EXCESS LIABILITY-SPD UNMET
- N980 FACILITY NOTICE REVIEW COMPLETE EXCESS LIABILITY
- C981 CI-FACIL- REV COMP EXCESS LIAB/SPD UNMET
- I009 RETRO PATIENT LIABILITY CHANGE-NF
- I012 FUNERAL AGREEMENT REFERRAL
- N900 MS-FACILITY NOTICE-GENERAL
- N911 S911 FACILITY NOTICE - APPROVAL ACH ONE MONTH
- N912 S912 FACILITY NOTICE - APPROVAL ACH TWO MONTHS
- N914 S914 FACILITY NOTICE-APPROVAL TEMP STAY
- N915 MS-FACILITY-APPROVAL-TEMP STAY FROM HCBS
- N962 MS - FACILITY - REINSTATE ACH PAYMENT
- N975 MS-FACILITY-FAILURE TO COMPLETE REVIEW
- N976 FACILITY- ACH PAYT END-TRANS TO NEW ACH
- N983 FACILITY NOTICE-LIABILITY CHANGE TWO MONTHS
- N985 TITLE: FACILITY - ACH PAYT END-MOVE TO IND LVG
- N987 FACILITY - ZERO LIABILITY-QMB
KEES Website Notices Medikan
- D100 MEDIKAN APPROVAL
- D200 MEDIKAN DENIED - FAIL TO PROVIDE INFO
- D204 MEDIKAN DENIED - FAMILY OF DECEASED
- D400 MEDIKAN CLOSURE - FAIL TO PROVIDE INFO
- D701 MEDIKAN TO MEDICAID - SSA APPROVED
- D832 OPEN MEDIKAN - MEDICAID PENDING
- D854 MEDIKAN TIME LIMIT INFORMATION