Kansas Family Medical Assistance
Manual (KFMAM)
Elderly & Disabled Medical Forms
| Form Number | Date | Form Name | File Format | |
| B-6 | 06/01/2017 | Trust and Annuity Clearance Request form | Word | �----� |
| DD-1103 | 11/04/16 | Authorization to Disclose Information to KDHE-DDS | �----� | |
| DD-1104 | 11/04/16 | Disability Determination Request Medical Assistance Case | Word | |
| DD-1105 | 11/04/16 | Disability Determination Data/Report Medical Assistance Case | Word | |
| DD-1106 | 11/04/16 | Medical Onset Date Verification | Word | |
| ES-3104.6 | 12/01/2016 | Determination Worksheet for Pickle Eligibles and other Protected Medical Groups | �----� | |
| ES-3121 | 1/15/2017 | Letter to Veteran's Administration for Benefit verification | Word | |
| ES-3162 | 2/17/2017 | Resource Assessment and Allowance Determination Form | �----� | |
| ES-3163 | 06/21/2017 | Income Allowance Determination Form | �----� | |
| ES-3167 | 11/04/16 | Annuities and the Kansas Medical Assistance Program Information for Medicaid Applicants and Recipients | Word | |
| ES-3167A | 11/04/16 | Annuities and the Kansas Medical Assistance Program Annuity Information Request | Word | |
| ES-3168 | 12/01/2016 | Prepaid Funeral Agreement | �----� | |
| ES-3169 | 11/04/16 | Irrevocable Assignment | �----� | |
| ES-3171 | 12/01/2016 | Irrevocable Collateral Assignment of Life Insurance | �----� | |
| IM-3121 | 1/30/2017 | Letter to Veteran's Administration for benefit verification | �----� | |
| M-2 | 07/03/17 | Notice of Intent to Transfer Resources | �----� | |
| M-3 | 06/29/17 | Notice of Intent to Allocate Income | �----� | |
| P-1 | 06/21/17 | Medical Necessity | �----� | |
| P-2 | 11/04/16 | Statement of Medical Necessity | Word | |
| W-9 | 06/21/17 | Transfer of Property Worksheet | �----� | |