The following forms are used in the administration of All Kids Share, All Kids Premium, or All Kids Rebate:
Notice of Change (Form 157KC)
Used to notify a family of a reduction in benefits, including the deletion of a child from the case, or of the cancellation of the case. This form is both centrally and locally issued.
Request for Medical Benefits for Additional Child (Form 243A)
Completed by a family to request All Kids Share, All Kids Premium, or All Kids Rebate for an additional child.
Request for Prior Coverage (Form 243KC)
Completed by a family to request prior coverage. The form can be requested from the HFS Central All Kids Unit or the All Kids Hotline.
Request for Prior Coverage - Notice of Approval (Form 243KCA)
Used by the HFS Central All Kids Unit to notify a family of their eligibility for prior coverage. Sent in response to Form 243KC.
Request for Prior Coverage - Notice of Denial (Form 243KCB)
Used by the HFS Central All Kids Unit to notify a family of their ineligibility for prior coverage. Sent in response to Form 243KC.
Instructions to Client (Form 267KC)
Used by DHS local offices to send with Form 2378KCA and Form 2378KCB to a family who is no longer eligible for All Kids Assist or Moms and Babies. This form briefly explains the All Kids Share, All Kids Premium, and All Kids Rebate programs.
Notice of Decision on Application for Health Benefits (Form 360KC)
Used to notify a family of the decision on their application for All Kids Share, All Kids Premium, or All Kids Rebate. Notifies a family of their ineligibility for All Kids Assist due to income. This form is both centrally and locally issued.
Renewal Form (Form 643KC)
Centrally generated to a family in the 10th month of their 12-month eligibility period. The family is required to complete and return the form with the appropriate verifications for their child(ren) to continue to receive All Kids Share, All Kids
Premium, or All Kids Rebate benefits.
Rebate Form (Form 2378KCB)
Required for each All Kids Rebate case to verify the amount the policyholder pays for the child(ren)'s health insurance. The form must be completed by either the employer or the insurance company at application, renewal, anytime a child is added to or
deleted from a All Kids Rebate case, and anytime the cost of the insurance changes.
Notice of Change Regarding Eligibility for Medical Assistance (Form 2434E)
Used to notify a person receiving All Kids Assist or Moms and Babies that their status has changed to All Kids Share, All Kids Premium, or All Kids Rebate.
Notice Regarding Copays (Form 3708)
Used by the HFS Central All Kids Unit to notify a family that their copay cap has been met for the year.
Notice Regarding Your Copay (Form 3708A)
Used by the HFS Central All Kids Unit to notify a family that has submitted receipts, that their copay cap has not been met.
All Kids Brochures (Form 3711)
Explains the All Kids Share, All Kids Premium, and All Kids Rebate programs.
Notice of Decision to Add a Child (Form 3718)
Centrally generated when a child is added to a All Kids Share, All Kids Premium, or All Kids Rebate case.
The manual version of this form is used by DHS Family Community Resource Center staff and the HFS Central All Kids Unit to notify a All Kids Share, All Kids Premium, or All Kids Rebate case of the denial of their request to add a child to an active All Kids Share, All Kids
Premium, or All Kids Rebate case.
All Kids Rebate - Notice of Approval (Form 3719)
Centrally generated by MMIS. Notifies the policyholder of the approval of a All Kids Rebate case. In addition, the caretaker relative receives a centrally generated Form 360KC.
All Kids Rebate - Notice of Change (Form 3719A)
Centrally generated by MMIS. Notifies the policyholder of a change in the Rebate payment or of the discontinuance of the case. If a child is deleted from a case or the case canceled, the caretaker relative also receives Form 157KC.
All Kids Report of Change (Form 3720)
Used by the DHS Family Community Resource Center and the HFS Central All Kids Unit to notify each other of changes reported to the wrong office.
Notice of Change in Premium and Copay Amounts (Form 3721)
Centrally generated form when a All Kids Premium family becomes All Kids Share.
All Kids Share/Premium/Rebate Change Report Form (Form 3722)
Centrally generated with Form 360KC approval notices. Explains changes the family is required to report and changes that are of advantage to the family to report. The form also has room for the family to complete and return to report any changes.
All Kids Share/Premium/Rebate Change Report Form (Form 3722A)
Manual version of Form 3722.
Information Regarding Copayments (Form 3726)
Centrally mailed with the All Kids Copay Tracking Form (Form 3726A) when a All Kids Share or All Kids Premium case is approved. This notice explains copays.
All Kids Copay Tracking Form (Form 3726A)
Centrally mailed form with Form 3726 to each approved All Kids Share and All Kids Premium case. Used by the family to keep track of their copays.
All Kids Renewal Notice (Form 3754)
Notifies the family that a renewal was completed and they remain eligible for All Kids Share or All Kids Premium.
All Kids Renewal Notice (Form 3754A)
Notifies the family that a renewal was completed and they remain eligible for All Kids Rebate.
All Kids Renewal Notice (Form 3754B)
Notifies a All Kids Premium family that a renewal was completed and they are eligible for All Kids Share.
All Kids Renewal Notice (Form 3754C)
Notifies a All Kids Share family that a renewal was completed and they are eligible for All Kids Premium.
All Kids Renewal Notice (Form 3754D)
Notifies a All Kids Share family that a renewal was completed and they are eligible for All Kids Assist or Moms and Babies.
All Kids Renewal Notice (Form 3754E)
Notifies a All Kids Premium family that a renewal was completed and they are eligible for All Kids Assist or Moms and Babies.
All Kids Renewal Notice (Form 3754F)
Notifies a All Kids Rebate family that a renewal was completed and they are eligible for All Kids Assist or Moms and Babies.
All Kids Renewal Notice (Form 3754G)
Notifies a All Kids Premium family that a renewal was completed and they are eligible for All Kids Rebate.
All Kids Renewal Notice (Form 3754H)
Notifies a All Kids Share family that a renewal is completed and they are eligible for All Kids Rebate.
All Kids Renewal Notice (Form 3754I)
Notifies a All Kids Rebate family that a renewal was completed and they are eligible for All Kids Premium.
All Kids Renewal Notice (Form 3754J)
Notifies a All Kids Rebate family that a renewal is completed and they are eligible for All Kids Share.
All Kids Language Translation Notice (Form 3764)
Used to ensure that a Limited English Person (LEP) who is a All Kids client has access to written information. Provides the message, "Important! This material contains information about health benefits. If you need help translating it, call
1-800-226-0768." This notice is inserted with the following centrally generated forms:
- Form 157KC,
- Form 360KC,
- Form 643KC,
- Form 3708,
- Form 3718,
- Form 3721, and
- Form 3722.
In addition to English, the message appears in the following languages:
- Arabic,
- Bosnian,
- Cambodian,
- Chinese,
- Croatian,
- Gujarati,
- Hindi,
- Korean,
- Polish,
- Russian,
- Serbian,
- Spanish,
- Tagalog,
- Urdu, and
- Vietnamese.
