Follow the steps to complete the KS KDHE Change Request Authorization

1. Press the ‘Get Form’ button to access the KS KDHE Change Request Authorization form and open it for editing.
2. Fill in the facility name where applicable to ensure proper identification of the requesting facility.
3. Enter the date and time of the request to provide context for the submission.
4. Include the facility contact person's name for direct communication regarding this request.
5. Provide the patient’s name and date of birth to connect the request with the correct individual.
6. Input the facility phone number and fax number for any communication related to this authorization.
7. Record the Medical Record Number (MRN) or Health Service Number (HSN) for identification purposes.
8. Supply the KDHE submission form number if available to help link this request with prior submissions.
9. Fill in the mother’s name, which may be required for certain patient information.
10. Indicate the specific missing information that needs to be completed or verified, such as the date of birth, collection date, physician’s name, specimen source, tests requested, diagnosis code, and birth weight.
11. Detail any incorrect or incomplete information along with the corresponding correct information.
12. If necessary, specify any additional tests required for the patient, making sure to note that one patient per fax is permitted.
13. Include the printed name and signature of the requester to validate the authorization. Ensure the date is also filled in.
14. Securely email or fax the completed form to the relevant department using the provided contact information.
15. Ensure that all changes are finalized, and watch for the confirmation of the corrected or amended reports.

Complete your KS KDHE Change Request Authorization online now for swift processing of your request.