Kansas Department of Health & Environment

Kansas Family Medical Assistance

Manual (KFMAM)


Eligibility Policy - 10/16/2021

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2320.02 Facility Birth Reporting Form for Medicaid Deemed Newborns - KC-4501 Facility Birth Reporting form for Medicaid Deemed Newborns, may be used by a medical facility to report the birth of an infant born to a Medicaid mother, if the child has been transferred to their medical facility due to a medical necessity after birth. The form will not be considered a valid request for coverage if all the fields are not filled out or the mother of the newborn did not receive Medicaid coverage in the month of birth. This form is not considered verification of Citizenship or Identity as it is not a birth confirmation letter.

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