Yy Details

Form E ( khc 3) is a document that needs to be filed with the court if you are asking the court to make decisions about your children. This form is used to ask for help with custody, visitation, and support issues. If you are considering filing this form, it is important to understand what it is and how it works. In this post, we will outline the basics of Form E khc 3 so that you can decide if it is right for you. stay tuned! more soon!. legalzoomdotcom/blog/family-law/form-e-khc3-court-orders-children/. as always check with an attorney in your state for more specific advice on your situation.

Below are some specifics of form e khc 3. This table can provide specifics of the form's size, finalization duration, and the blanks you're needed to fill.

QuestionAnswer
Form NameForm E Khc 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameskidney health care program application, dshs, yy, xr

Form Preview Example

TRAVEL CLAIM FORM (KHC-3)

KIDNEY HEALTH CARE

PO Box 149347 (MC 1938)

Austin, Texas 78714-9347

1-800-222-3986

FOR HOME DIALYSIS AND KIDNEY TRANSPLANT CLIENTS

1. Tell us who you are. Please print or type.

Last Name

 

First Name

 

Middle Initial

 

 

 

 

 

Phone Number

 

Social Security Number (optional)

 

KHC Number

2. Tell us where you went and why.

You need to fill 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

FULL LOCATION ADDRESS

 

REASON FOR TRIP

MM/DD/YY

PLACE YOU WENT TO SEE

(Use a code from the list or choose “other”)

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

(Fill in the back)

 

 

 

 

 

 

3. Sign below to show that you understand and agree to this:

 

 

 

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 put down things that are not true, I may be doing something that is against the law. In that case, I could lose my benefits, have to pay money back, or face legal actions.

Your signature

Witness signature (if client cannot sign)

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://www.dshs.state.tx.us for more information on Your Right to Privacy. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)

E-KHC-3 Page 1 of 2

THIS FORM MAY BE COPIED

Rev. 06-2015

Last Name

First Name

Middle Initial

KHC #

Fill in the blanks below only if you checked the box marked “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). You can ask for help from your doctor or someone else where you get your care if you have trouble filling this part out.

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

1.Trip Date(s):

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

3. Describe how the trip(s) 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:

E-KHC-3 Page 2 of 2

THIS FORM MAY BE COPIED

Rev. 06-2015

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