Initial Client Documents

Date

Consumer County ID#:

First Name

Last Name

DOB:

Phone

Address

City

State

Postal Code

County

Financial Agreement for Services

I hereby request that TCM of KS serve as my Targeted Case Manager (TCM) effective on

until TCM of KS is notified by the County Developmental Disability Organization (CDDO) that TCM services are no longer requested. At that time, services will be discontinued with TCM of KS by the process in place with the County Developmental Disability Organization (CDDO).

Consent Statements

I understand TCM services are paid through Medicaid funding. The person served will not be charged for these services nor are they responsible for the billing of TCM services.I understand that I may be financially responsible for TCM services if my Medicaid is terminated or I become ineligible for the service.Kansas Medicaid will require that TM of KS bill primary insurance, as Medicaid is the payer of last resort.I understand by accepting TCM services, I must participate in person-centered support plan development at least annually.I understand by accepting TCM services, my TCM will make monthly contact with me.

Authorization for Medical Treatment

hereby authorize TCM of KS to provide the following medical treatment. 1. Assist in medication administration.
2. Perform emergency CPR. Perform routine first aid.
3. Secure necessary medical services.
4. Provide private health information to first responders in case of medical emergency.

Consent Statements

I have read the above Authorization for Medical Treatment and do hereby acknowledge that I fully understand the terms and conditions of this releaseI understand that I have the right to revoke this authorization at any time by notifying in writing and presenting to TCM of KS.
I understand that this authorization is valid as long as TCM of KS is the Manager of Record.Kansas Medicaid will require that TCM of KS bill primary insurance, as Medicaid is the payer of last resort.

Authorization For Release of Healthcare Information

Complete this if you have primary insurance (other than Medicaid)

hereby authorize the release and disclosure of my healthcare information as described in this authorization.

I authorize the release and disclosure of any information about payment of Targeted Case Management Services, and/or current coverage to TCM of KS.

I authorize the release and disclosure of records about my primary insurance and treatment to TCM of KS.

Primary Insurance Information

Name of Policy Holder

Person Covered

Company Name:

Policy #:

Group #:

Upload a copy of all insurance cards (front and back)

My KanCare/Medicaid Provider is:

Name of person completing this form

Role of person completing this form

Person in servicesNatural or Adoptive Parent (of minor child)Legal GuardianAuthorized Representative