Kansas Department for Aging and Disability Services Forms
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Form I/DD-1 "I/DD Medicaid Waiver Individual Choice" - Kansas
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Instructions for Form KDADS-PRTF-01 "Psychiatric Residential Treatment Facility Financial and Statistical Report (Cost Report)" - Kansas
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KDADS Form SS-025 "Iii-E Caregiver Assessment Plan" - Kansas
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KDADS Form SS-003 "Abbreviated Uniform Assessment Instrument" - Kansas
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Form UPR-001 "Uniform Program Registration" - Kansas
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KDADS Form SS-005 "Uniform Assessment Instrument" - Kansas
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KDADS Form UPR-001 "Uniform Program Registration" - Kansas
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KDADS Form SI-002 "Standard Intake & Information Form" - Kansas
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KDADS Form SS-009 "Customer Service Worksheet" - Kansas
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58 votes
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KDADS Form FAI-001 "Functional Assessment Instrument" - Kansas
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KDADS Form SS-012 "Sca/Oaa Customer Rights and Responsibilities" - Kansas
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Formulario KDADS FAI200 "Documento De Evaluacion De La Funcion Resultado Del Nivel De Cuidado" - Kansas (Spanish)
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Form KDADS FAI200 "Functional Assessment Instrument Level of Care Score Outcome" - Kansas
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KDADS Form SS-028 "Legal Services Reporting Form" - Kansas
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KDADS Form SS-046 "Corrective Action Plan" - Kansas
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KDADS Form SS-043 "Customer Code of Conduct" - Kansas
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Form MS-2015 "Nursing Facility Provider Agreement" - Kansas
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20 votes
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261 KB
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KDADS Form AP-2204 "Limited Scope License" - Kansas
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Form AP-2204 "License Application" - Kansas
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Instructions for Form MS-2004 "Nursing Facility Financial and Statistical Report" - Kansas
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15 votes
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Instructions for Form AU-3902-A "Monthly Census Summary" - Kansas
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"Adult Community Mental Health Center Screening Form" - Kansas
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"Youth Community Mental Health Center Screening Form" - Kansas
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"Administrative Transfer Request Form Sia to State Hospital" - Kansas
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"Crisis Exception Request: Physician Statement" - Kansas
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Attachment A "Initial Clinical Eligibility Form" - Kansas
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"Brain Injury Program Eligibility Attestation" - Kansas
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"Idd Notification Form With Provisional Plan of Care" - Kansas
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"Individuals Authorized to Sign Community Support Medication Enrollment Form" - Kansas
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"Resident Review Check List" - Kansas
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"Community Support Medication Program (Csmp) Enrollment Application" - Kansas
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"Idd Request for Waiver" - Kansas
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"Open Records Request" - Kansas
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"Authorization for Release of Protected Health Information" - Kansas
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"Resident Review Required Documentation" - Kansas
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![Form I/DD-1 "I/DD Medicaid Waiver Individual Choice" - Kansas](https://data.templateroller.com/pdf_docs_html/2025/20259/2025969/form-i-dd-1-i-dd-medicaid-waiver-individual-choice-kansas.png "Form I/DD-1 "I/DD Medicaid Waiver Individual Choice" - Kansas")
![Instructions for Form KDADS-PRTF-01 "Psychiatric Residential Treatment Facility Financial and Statistical Report (Cost Report)" - Kansas](https://data.templateroller.com/pdf_docs_html/2009/20099/2009933/instructions-for-form-kdads-prtf-01-psychiatric-residential-treatment-facility-financial-and-statistical-report-cost-report-kansas.png "Instructions for Form KDADS-PRTF-01 "Psychiatric Residential Treatment Facility Financial and Statistical Report (Cost Report)" - Kansas")
![KDADS Form SS-025 "Iii-E Caregiver Assessment Plan" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22680/2268081/kdads-form-ss-025-iii-e-caregiver-assessment-plan-kansas.png "KDADS Form SS-025 "Iii-E Caregiver Assessment Plan" - Kansas")
![KDADS Form SS-003 "Abbreviated Uniform Assessment Instrument" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22680/2268080/kdads-form-ss-003-abbreviated-uniform-assessment-instrument-kansas.png "KDADS Form SS-003 "Abbreviated Uniform Assessment Instrument" - Kansas")
![Form UPR-001 "Uniform Program Registration" - Kansas](https://data.templateroller.com/pdf_docs_html/2147/21478/2147886/form-upr-001-uniform-program-registration-kansas.png "Form UPR-001 "Uniform Program Registration" - Kansas")
![KDADS Form SS-005 "Uniform Assessment Instrument" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22680/2268082/kdads-form-ss-005-uniform-assessment-instrument-kansas.png "KDADS Form SS-005 "Uniform Assessment Instrument" - Kansas")
![KDADS Form UPR-001 "Uniform Program Registration" - Kansas](https://data.templateroller.com/pdf_docs_html/2064/20645/2064518/kdads-form-upr-001-uniform-program-registration-kansas.png "KDADS Form UPR-001 "Uniform Program Registration" - Kansas")
![KDADS Form SI-002 "Standard Intake & Information Form" - Kansas](https://data.templateroller.com/pdf_docs_html/1805/18059/1805909/kdads-form-si-002-standard-intake-information-form-kansas.png "KDADS Form SI-002 "Standard Intake & Information Form" - Kansas")
![KDADS Form SS-009 "Customer Service Worksheet" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17995/1799500/kdads-form-ss-009-customer-service-worksheet-kansas.png "KDADS Form SS-009 "Customer Service Worksheet" - Kansas")
![KDADS Form FAI-001 "Functional Assessment Instrument" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17994/1799452/kdads-form-fai-001-functional-assessment-instrument-kansas.png "KDADS Form FAI-001 "Functional Assessment Instrument" - Kansas")
![KDADS Form SS-012 "Sca/Oaa Customer Rights and Responsibilities" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17994/1799494/kdads-form-ss-012-sca-oaa-customer-rights-and-responsibilities-kansas.png "KDADS Form SS-012 "Sca/Oaa Customer Rights and Responsibilities" - Kansas")
![Formulario KDADS FAI200 "Documento De Evaluacion De La Funcion Resultado Del Nivel De Cuidado" - Kansas (Spanish)](https://data.templateroller.com/pdf_docs_html/2009/20099/2009931/form-kdads-fai200-documento-de-evaluacion-de-la-funcion-resultado-del-nivel-de-cuidado-kansas-spanish.png "Formulario KDADS FAI200 "Documento De Evaluacion De La Funcion Resultado Del Nivel De Cuidado" - Kansas (Spanish)")
![Form KDADS FAI200 "Functional Assessment Instrument Level of Care Score Outcome" - Kansas](https://data.templateroller.com/pdf_docs_html/2009/20099/2009932/form-kdads-fai200-functional-assessment-instrument-level-of-care-score-outcome-kansas.png "Form KDADS FAI200 "Functional Assessment Instrument Level of Care Score Outcome" - Kansas")
![KDADS Form SS-028 "Legal Services Reporting Form" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17995/1799502/kdads-form-ss-028-legal-services-reporting-form-kansas.png "KDADS Form SS-028 "Legal Services Reporting Form" - Kansas")
![KDADS Form SS-046 "Corrective Action Plan" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17994/1799490/kdads-form-ss-046-corrective-action-plan-kansas.png "KDADS Form SS-046 "Corrective Action Plan" - Kansas")
![KDADS Form SS-043 "Customer Code of Conduct" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17994/1799496/kdads-form-ss-043-customer-code-conduct-kansas.png "KDADS Form SS-043 "Customer Code of Conduct" - Kansas")
![Form MS-2015 "Nursing Facility Provider Agreement" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22681/2268137/form-ms-2015-nursing-facility-provider-agreement-kansas.png "Form MS-2015 "Nursing Facility Provider Agreement" - Kansas")
![KDADS Form AP-2204 "Limited Scope License" - Kansas](https://data.templateroller.com/pdf_docs_html/1805/18059/1805912/kdads-form-ap-2204-limited-scope-license-kansas.png "KDADS Form AP-2204 "Limited Scope License" - Kansas")
![Form AP-2204 "License Application" - Kansas](https://data.templateroller.com/pdf_docs_html/1799/17994/1799481/form-ap-2204-license-application-kansas.png "Form AP-2204 "License Application" - Kansas")
![Instructions for Form MS-2004 "Nursing Facility Financial and Statistical Report" - Kansas](https://data.templateroller.com/pdf_docs_html/2025/20259/2025966/instructions-for-form-ms-2004-nursing-facility-financial-and-statistical-report-kansas.png "Instructions for Form MS-2004 "Nursing Facility Financial and Statistical Report" - Kansas")
![Instructions for Form AU-3902-A "Monthly Census Summary" - Kansas](https://data.templateroller.com/pdf_docs_html/2244/22442/2244247/instructions-for-form-au-3902-a-monthly-census-summary-kansas.png "Instructions for Form AU-3902-A "Monthly Census Summary" - Kansas")
!["Adult Community Mental Health Center Screening Form" - Kansas](https://data.templateroller.com/pdf_docs_html/2382/23820/2382048/adult-community-mental-health-center-screening-form-kansas.png ""Adult Community Mental Health Center Screening Form" - Kansas")
!["Youth Community Mental Health Center Screening Form" - Kansas](https://data.templateroller.com/pdf_docs_html/2382/23820/2382049/youth-community-mental-health-center-screening-form-kansas.png ""Youth Community Mental Health Center Screening Form" - Kansas")
!["Administrative Transfer Request Form Sia to State Hospital" - Kansas](https://data.templateroller.com/pdf_docs_html/2382/23820/2382047/administrative-transfer-request-form-sia-to-state-hospital-kansas.png ""Administrative Transfer Request Form Sia to State Hospital" - Kansas")
!["Crisis Exception Request: Physician Statement" - Kansas](https://data.templateroller.com/pdf_docs_html/2211/22111/2211126/crisis-exception-request-physician-statement-kansas.png ""Crisis Exception Request: Physician Statement" - Kansas")
![Attachment A "Initial Clinical Eligibility Form" - Kansas](https://data.templateroller.com/pdf_docs_html/2168/21686/2168693/attachment-a-initial-clinical-eligibility-form-kansas.png "Attachment A "Initial Clinical Eligibility Form" - Kansas")
!["Brain Injury Program Eligibility Attestation" - Kansas](https://data.templateroller.com/pdf_docs_html/2086/20868/2086815/brain-injury-program-eligibility-attestation-kansas.png ""Brain Injury Program Eligibility Attestation" - Kansas")
!["Idd Notification Form With Provisional Plan of Care" - Kansas](https://data.templateroller.com/pdf_docs_html/2025/20259/2025968/idd-notification-form-with-provisional-plan-of-care-kansas.png ""Idd Notification Form With Provisional Plan of Care" - Kansas")
!["Individuals Authorized to Sign Community Support Medication Enrollment Form" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22681/2268117/individuals-authorized-to-sign-community-support-medication-enrollment-form-kansas.png ""Individuals Authorized to Sign Community Support Medication Enrollment Form" - Kansas")
!["Resident Review Check List" - Kansas](https://data.templateroller.com/pdf_docs_html/2009/20099/2009934/resident-review-check-list-kansas.png ""Resident Review Check List" - Kansas")
!["Community Support Medication Program (Csmp) Enrollment Application" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22681/2268116/community-support-medication-program-csmp-enrollment-application-kansas.png ""Community Support Medication Program (Csmp) Enrollment Application" - Kansas")
!["Idd Request for Waiver" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22681/2268135/idd-request-for-waiver-kansas.png ""Idd Request for Waiver" - Kansas")
!["Open Records Request" - Kansas](https://data.templateroller.com/pdf_docs_html/2268/22680/2268091/open-records-request-kansas.png ""Open Records Request" - Kansas")
!["Authorization for Release of Protected Health Information" - Kansas](https://data.templateroller.com/pdf_docs_html/1805/18058/1805890/authorization-release-protected-health-information-kansas.png ""Authorization for Release of Protected Health Information" - Kansas")
!["Resident Review Required Documentation" - Kansas](https://data.templateroller.com/pdf_docs_html/1816/18160/1816008/resident-review-required-documentation-kansas.png ""Resident Review Required Documentation" - Kansas")