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Kansas Health Care Stabilization Fund Compliance Form

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  • Section A - Health Care Provider Identification and Residency Status

  • Enter the Health care providers last name or the complete name of medical facility or business entity name.
    • 9. Legal Residence

      Legal residence address of health care professional or street address location of medical care facility or business: NOTE: For health care professionals, this must be the home address (legal domicile).
    • 10. Business Mailing Address

    • Section B - Commercial Insurance Information

      NOTE: A certificate of insurance is required for all non-resident health care providers. The information on this compliance form will not be accepted nor will the health care provider be in compliance with KSA 50-3401 et seq until the certificate of insurance and the appropriate HCSF premium surcharge have been received and accepted.
      • MM slash DD slash YYYY
      • MM slash DD slash YYYY
        • Section C - Health Care Stabilization Fund Coverage

        • Section D - Certification

        • Upload supporting Documentation if applicable
          Drop files here or
          Accepted file types: pdf, Max. file size: 256 MB.

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