
FAX 1-844-264-6285). This form is not used for persons in an Assisted Living Facility. A. Resident Information First Name: Last Name: SSN: Gender: Date of Birth: Client ID #: Responsible Person Name: Relationship: Responsible Person Address: Phone: B. Facility Information (Assisted Living Do Not Complete) Facility Name: Phone: Facility Address: Fax: Name of Agency/Person Placing Resident: Facility NPI: Administrator/Designee: C. CARE/PASRR/Pre-Admission Screening (Responses to.
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How to fill out the KS KanCare MS-2126 online
Completing the KS KanCare MS-2126 form is essential for facilities to notify the KanCare Clearinghouse of a resident's admission or discharge. This guide provides clear, step-by-step instructions to help you accurately fill out this form online.
Follow the steps to complete the KS KanCare MS-2126 effectively.
- Press the ‘Get Form’ button to access the KS KanCare MS-2126 and open it in your selected editor.
- Begin with Section A, 'Resident Information.' Enter the first name, last name, Social Security Number (SSN), gender, date of birth, and client ID number. Include the responsible person's name, relationship, address, and phone number.
- Move to Section B, 'Facility Information.' Fill in the facility's name, phone number, address, fax number, the name of the agency or person placing the resident, the facility's National Provider Identifier (NPI), and the administrator or designee's name.
- Advance to Section C, 'CARE/PASRR/Pre-Admission Screening.' Answer all questions regarding whether a screening is required, and if it is, specify if it is for special admission and provide relevant dates.
- Proceed to Section D, 'Facility Admission.' Document the date the resident was admitted, anticipate the length of stay (less than 30 days, temporary, or permanent), and specify the current level of care in your facility. Also, indicate whether the resident was admitted from another facility and provide details if applicable.
- In Section E, 'Temporary Absence,' fill this out only if the resident is absent from the facility for more than 30 days. Provide the type of facility and the date the resident left and returned or plans to return.
- Complete Section F if the resident does not intend to return or has passed away. Fill in the discharge date, date deceased, and place they have been discharged to.
- Review the entire form for completeness. Ensure each section is filled out according to the requirements.
- After filling out the form, you can save the changes, download, print, or share the completed KS KanCare MS-2126 as necessary.
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