Non State Employer Groups Administrative
Manual
Appendices
A1. Kansas Administrative Regulation 108-1-3
A2. Kansas Administrative Regulation 108-1-4
B. SEHP Enrollment Form
B1. SEHP Enrollment Form Key
B2. SEHP Enrollment Form Instructions
C. SEHP Change Form
C1. SEHP Change Form Key
C2. SEHP Change Form Instructions
D. SEHP TEFRA Form
E. SEHP Request for Waiver of Thirty Day Waiting Period
F. SEHP Health Plan Communication Form
G. SEHP Prescription Drug Advance Purchase Certificate
G1. SEHP Prescription Drug Advance Purchase Policy
H. SEHP Caremark Prescription Reimbursement Standard Claim Form
I. SEHP Sample Agency Medicare Part B Memo
J. SEHP End State Renal Disease Questionnaire
K. SEHP Dependent Grandchild Affidavit
L. SEHP Affidavit and Application for Coverage of Permanent and Totally Disabled Dependent Child
M. SEHP Affidavit of Common Law Marriage
N. SEHP Staff Contact List
O. SEHP Health Plan Providers' Contact Information
P. SEHP Health Plan Coverage Begin Dates for Newly Hired Employees
Q. SEHP Plan Year 2012 COBRA Rates
R. SEHP Specific HIPAA Authorization
S. SEHP Appointment of Personal Representative Form
S1. SEHP Revocation of Personal Representative Form
T. SEHP Direct Bill ACH Form
U. SEHP Non State Employer Group Certification Form