Form E Khc 3 PDF Details

Managing the intricacies of healthcare needs can become considerably more challenging when they demand frequent travel for treatments, especially for individuals grappling with end-stage renal disease or those who have undergone a kidney transplant. Acknowledging this, the E Khc 3 form emerges as a crucial document designed to lighten the financial burden associated with such healthcare-related travels. This form allows patients to claim reimbursements for travel expenses incurred due to medical visits, treatments, or check-ups directly linked to kidney health maintenance. Detailed within the form are sections meant for personal information, along with a comprehensive breakdown of trip details, including dates, destinations, and the specific reasons for each journey, annotated with predetermined codes that categorize the nature of each trip. Additionally, the form incorporates a client acknowledgement part which emphasizes the honesty and accuracy of the submitted information, and delineates the potential consequences of any misinformation. The provision for stating trips not listed under the given codes, including a segment on the reverse side for elaboration, ensures that all aspects of the patient's travel requirements are considered. Moreover, information about the privacy rights of clients underscores the form's adherence to legal norms concerning personal data protection. Through this form, patients are not only supported in managing their kidney-related health needs but are also assured of a structured process to alleviate some of the financial strains of their treatment journeys.

QuestionAnswer
Form NameForm E Khc 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameskhc, kidney healthcare of texas application, xr, texas kidney health care application

Form Preview Example

Kidney Health Care

Travel Claim Form for Home Dialysis and Kidney Transplant Patients

Client Information

Last Name

First Name

Middle Initial

Phone Number

Social Security Number (optional)

KHC Number

Trip Information

Provide your monthly travel details by filling in all four columns of this table. For the last column, choose the code from the list below that best describes the reason for your trip. You will only be reimbursed for four trips you already traveled per month which is related to end-stage renal disease or kidney transplant.

Access Surgery

AS

Epogen

EP

Peritoneal Clinic Visit

PC

Access Complication

AC

Lab tests, X-rays or other

XR

Tests before your transplant

BT

PD Support

PD

Nephrologist Visit

NE

Transplant Surgery

TS

Check-up after your transplant

AT

 

 

 

 

If the reason for your trip is not on the list, then: (1) Check the box marked ‘Other’ and (2) Fill in the back of this form.

 

Date

 

 

Name of Person or Place You

 

 

Full Location Address

 

 

Reason for Trip

 

 

 

 

 

 

 

 

(Use a code from list above or

 

 

MM/DD/YY

 

 

Went to See

 

 

 

 

 

 

 

 

 

 

 

 

 

choose ‘Other’)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Acknowledgement

I agree that each trip shown above was for travel and mileage that is allowed. I also agree that no other agency can pay me back for the trip and mileage. I understand that if I hold back any facts or submit information that is not true, I may be doing something that is against the law, which in that case I could lose my benefits, have to pay money back, or face legal actions.

Client Signature

Witness Signature (if client cannot sign)

Kidney Health Care • MC 1938 • PO Box 149347 • Austin, Texas 78714-9347

1-800-222-3986 • khc@hhsc.state.tx.us

Last Name

First Name

Middle Initial

KHC Number

Fill in the blanks below only if you have checked the box ‘Other’ on the other side of this form. KHC needs to know some things in order to figure out if it can pay for your trip(s). If you have trouble filling this part out, you can ask for help from your doctor or someone else from where you get your care.

If KHC has already reviewed and approved your travel for this condition, you only need to fill out Field number 3.

1.Date of Trip(s):

2.Where did you go? Place or Doctor’s Name(s), Street Address(es), and Phone Number(s):

3. Describe how the trip is related to your end-stage renal disease or kidney transplant:

KHC will do a medical review with this information. KHC may call your doctor(s) for more information. KHC will tell you its decision after it does the review. If KHC decides that the trip(s) are related to end-stage renal disease or a kidney transplant, your KHC file will be updated. This will allow you to make future trips related to the condition.

For Use By KHC Reviewer ONLY

Reviewer

Date

Allow Trip(s)

Disallow Trip(s)

Comments:

Notice about Your Right to Privacy

Except in some cases, you have the right to ask for and know the information the State of Texas has about you. You can ask for it at any time. You can get it and make sure it is right. You have the right to ask the state agency to correct anything that is wrong. See http://hhs.texas.gov for more information on Your Right to Privacy. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)

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completing travel claim form khc 3 step 1

Write the information in Other Fill in the back, Other Fill in the back, Other Fill in the back, Client Acknowledgement I agree, Client Signature, Witness Signature if client cannot, Kidney Health Care MC PO Box, and khchhscstatetxus.

travel claim form khc 3 Other Fill in the back, Other Fill in the back, Other Fill in the back, Client Acknowledgement I agree, Client Signature, Witness Signature if client cannot, Kidney Health Care  MC   PO Box, and khchhscstatetxus fields to complete

In the If KHC has already reviewed and, Date of Trips, Where did you go Place or Doctors, and Describe how the trip is related part, point out the relevant data.

part 3 to entering details in travel claim form khc 3

Make sure you write down the rights and responsibilities of the parties inside the KHC will do a medical review with, For Use By KHC Reviewer ONLY, Comments, Date, Allow Trips, Disallow Trips, and Notice about Your Right to Privacy space.

travel claim form khc 3 KHC will do a medical review with, For Use By KHC Reviewer ONLY, Comments, Date, Allow Trips, Disallow Trips, and Notice about Your Right to Privacy blanks to fill out

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