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The following brochures are available on this
site or printed copies may be requested from the Fund. The following
list includes a brief description of each brochure and the specific HCSF
forms which can be found in each of the brochures. After previewing or
printing these brochures in the PDF format, use your browser's back
button to return to the Fund web site. If you should note any problems
with any of the brochures or wish to make a comment about this new feature
please send us an email. |
|
Brochure Title |
EDITION DATE |
Brief Description |
|
Forms Included In Brochure |
|
General Information Brochure
Click here for PDF version of brochure
|
July 30, 2008 |
Basic information about the Fund.
|
|
None |
Health Care Stabilization Fund FY 2009 Annual Premium
Surcharge and Rating Classification System
Click here for PDF
version of FY 2009 brochure
|
May 9, 2008
|
Surcharge rating information for Kansas
resident health care providers
|
|
Request
to Increase Health Care Stabilization Fund Coverage Limits form (page 13)
Request to Decrease Health Care Stabilization Fund
Coverage limits (page 14)
Fund Surcharge Rating System Agreement (page 15)
Notice of Basic Coverage form (page 16) |
|
NBC forms only |
FY 2008 NBC form
FY 2009 NBC form
|
|
PDF versions
|
|
|
Helpful Information for Completing and Submitting the Health
Care Stabilization Fund Refund Request form
Click here
for PDF version of brochure
|
April 25, 2006 |
Information
about how to request a refund of surcharge payments due to
overpayment, mid-coverage period termination or other situation. |
|
Health Care Stabilization Fund Refund Request form (page 2) |
Non-resident health care provider general information and
guidelines
FY2009 Non-resident - Click here for PDF version of brochure
|
May 21, 2008
|
Information and guidelines for non-resident
health care providers who are providing professional services in Kansas. |
|
Instructions and surcharge rate calculation worksheet for
non-resident health care providers who are or will be rendering professional
services in Kansas (page 2) Kansas health Care
Provider Insurance Availability Act Non-resident health Care Provider
Certification Form (page 7)
Short Form - Non-Resident health Care Provider
Certification Form - No Longer Practicing in Kansas (page 8) |
Guidelines for forms to be used by insurers providing the
required basic coverage for Kansas health care providers
Click here for PDF version of brochure
|
April 25, 2006 |
Insurer related forms. Some excerpts of
the Fund law (for ease of reference only). |
|
Cancellation/termination notice requirements of the Health
Care Stabilization Fund law, includes a sample termination notice form (page
5) Admitted Carrier Declaration of Compliance With
The Kansas Health Care Provider Insurance Availability Act form (Kansas
Insurance Department form, page 6)
Non-Admitted Insurer Declaration of Compliance With The
Kansas Health Care Provider Insurance Availability Act form (page 8, with
instructions and guidelines on page 7)
Membership Agreement for Kansas Health Care Providers
Insurance Availability Plan form (Kansas Insurance Department form, page 9)
Mandatory Health Care Provider Claim Information Report
Form Initial Report form (page 10, with instructions on page 11)
|
Guidelines for the optional Fund tail coverage, surcharge
rates effective July 1, 2006 to June 30, 2007
Click here for PDF version of brochure
Guidelines for the optional Fund tail coverage, surcharge rates effective
July 1, 2007 to June 30, 2008
Click here for PDF version of brochure
|
April 25, 2006 |
Information for health care providers who are
becoming inactive and have less than five years of Fund coverage
|
|
Application for Exemption (pages 6 and 7)
Affidavit of Retirement (page 8)
Affidavit of Disability (page 9)
Affidavit of Temporary Absence (page 10)
Affidavit of Extension on Temporary Exemption (page 11)
Affidavit of Temporary Absence Due to Military Duty (page
12)
|
Guidelines for the self-insurance provisions for the Fund
Click
here for PDF version of brochure
|
April 2008 |
Information to assist eligible health care
providers in understanding and applying for basic coverage self-insurance
status. |
|
Application for Certificate of Self-insurance form (page 4)
Kansas Health Care Stabilization Fund Notice of Basic
Coverage, Instructions - Self-insured Program form (page 5)
Self-insured Professional Liability Coverage Questionnaire
for the Annual Premium Based on the Rules and Rates of the Health Care
Provider Insurance Availability Plan (page 6)
Self-insured Declaration of Financial Compliance with
Health Care Provider Insurance Availability Act to the Health Care
Stabilization Fund Board of Governors form (page 7)
|
Attorney Payment Request
related forms
Click on the
desired form shown in the column to the right
|
January 1, 2007 |
Forms used in connection with billings sent
by Fund attorneys and billing personnel. |
|
Attorney Payment Request cover sheet
In Microsoft Word
format
In Adobe PDF format
Vendor Payment Request form
In Microsoft Word format
In Adobe PDF format
W-9 Request for Taxpayer Identification
Number form
In Adobe PDF format only |