Active State Administration Manual
Appendices
A. Kansas Administrative Regulation 108-1-1
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
D1. Sample TEFRA Letter - Employee 65
D2. Sample TEFRA Letter - Spouse 65
E. SEHP Employer's Waiver of Health Plan Participation
F. SEHP Request for Waiver of Thirty Day Waiting Period
G. SEHP Health Plan Communication Form
H. SEHP Caremark Prescription Reimbursement Standard Claim Form
I. SEHP Prescription Drug Advance Purchase Certificate
I1. SEHP Prescription Drug Advance Purchase Policy
J. SEHP Sample Agency Medicare Part B Memo
K. SEHP End State Renal Disease Questionnaire
L. SEHP Dependent Grandchild Affidavit
M. SEHP Affidavit and Application for Coverage of Permanent and Totally Disabled Dependent Child
N. SEHP Affidavit of Common Law Marriage
O. SEHP Staff Contact List
P. SEHP Health Plan Providers' Contact Information
Q. SEHP Health Plan and FSA Coverage Begin Dates for Newly Hired Employees
R. SEHP FSA Eligibility Table
S. SEHP Plan Year 2012 COBRA Rates
T. SEHP SampleFMLA Billing Letter
T1. SEHP SampleFMLA Termination Letter
T2. SEHP SampleFMLA 15 Day Letter
U. SEHP Sample Worker's Compensation Employee on TDD
V. SEHP Specific HIPAA Authorization
W. SEHP Appointment of Personal Representative Form
W1. SEHP Revocation of Personal Representative Form
X. SEHP Paid Extended Absence of Sabbatical Leave
Y. SEHP Direct Bill ACH Form
Z. SEHP FSA Enrollment Change Form
Z1. SEHP HSA Enrollment Change Form
AA. SHaRP Table for COBRA Eligible Individuals