Form E Khc 3 PDF 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?Yes
Fillable fields36
Avg. time to fill out7 min 46 sec
Other namesnephrologist, khc, texas kidney health care application, kidney healthcare of texas 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)

How to Edit Form E Khc 3 Online for Free

It won't be a challenge to obtain travel claim form khc 3 using our PDF editor. Here's how you may easily develop your document.

Step 1: Click the "Get Form Here" button.

Step 2: After you've entered the travel claim form khc 3 edit page, you'll see all actions you may use with regards to your file at the upper menu.

Enter the necessary details in every single segment to create the PDF travel claim form kh, c 3

completing khc step 1

Write the information in Other, Fill, in, the, back Other, Fill, in, the, back Other, Fill, in, the, back Client, Acknowledgement Client, Signature and Witness, Signature, if, client, cannot, sign

khc OtherFillintheback, OtherFillintheback, OtherFillintheback, ClientAcknowledgement, ClientSignature, and WitnessSignatureifclientcannotsign fields to complete

In the Date, of, Trips part, point out the relevant data.

part 3 to entering details in khc

Make sure you write down the rights and responsibilities of the parties inside the For, Use, By, KH, C, Reviewer, ONLY, Reviewer Comments, Date, Allow, Trips and Disallow, Trips space.

khc ForUseByKHCReviewerONLYReviewer, Comments, Date, AllowTrips, and DisallowTrips blanks to fill out

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