The 18 Kansas forms clinicians complete, from Division of Vehicles medical and vision forms to KMAP Medicaid requests, KSHSAA physicals and the TPOPP.
This page lists the Kansas forms clinicians complete, grouped by program, and each group links to its program hub. The Division of Vehicles uses two: DV-124M, the medical form on whether a patient can drive safely, and DV-124V for vision. TR-159 certifies a disability for a parking placard, plate or decal. Kansas Medicaid (KMAP) uses the General Prior Authorization Request, a certification for transportation services and Certificate of Medical Necessity 60-14. Schools ask for the KSHSAA Pre-Participation Physical Evaluation.
Kansas workers' comp has no state physician report or work-status form. Treating physicians write narrative reports, and the one form, K-WC-R 87-7, is the case manager's closure report. The DV-124M exam must be within the last 90 days, and TR-159 does not accept rubber-stamp signatures. A concussion return to play needs a written MD or DO release under Kansas law. The TPOPP serves as the POLST form in both Kansas and Missouri. The KSHSAA physical also comes in Spanish.
K-WC-R 87-7Medical manager's report closing a medical-management (case management) file, stating the reason (return to work, release with or without restrictions, carrier request, vocational referral) and certifying the job is within the worker's medical restrictions.
Medical and/or psychological professional's report on whether the patient can safely operate a motor vehicle, recommended restrictions, and Medical Advisory Board review.
Vision professional's report of acuity, fields and recommended restrictions (or Medical Advisory Board review) for a driver referred to the Medical/Vision Unit.
Applies for a disabled identification placard, disabled license plate or decal, with a healing arts licensed professional's certification under K.S.A. 8-1,124 (temporary or permanent).
Medical provider certifies a beneficiary's need for a specific level of non-emergency medical transportation.
General fee-for-service prior authorization request for medical services and items without a service-specific PA form.
Physician order and medical necessity documentation for blood glucose testing supplies under Kansas Medicaid.
Prior authorization request documenting medical necessity for a power wheelchair.
Documents medical necessity for EPSDT (KAN Be Healthy) services beyond State Plan limits for members under 21; lists FFS and each KanCare MCO's PA contacts.
Certificate of medical necessity attached to claims for items/services that require documentation of medical necessity.
Child health assessment required no later than 60 days after enrollment in a Kansas licensed child care facility, including providers' own children.
History, physical exam and medical eligibility required for KSHSAA athletics and cheer; kept in the student's school record.
Health care provider's recommended academic accommodations for a student returning to class after a concussion.
Graduated return-to-play progression with the physician's written release required by K.S.A. 72-7119 before a student returns to full participation after a concussion.
Physician release allowing a wrestler with a skin lesion to compete.
Portable POLST-paradigm order for CPR, medical interventions and nutrition used across Kansas and Missouri.
Case report of a notifiable disease or condition by a health care provider to KDHE / the local health department.
Provider report of positive tests and treatment for HIV, syphilis, gonorrhea and chlamydia (KSA 65-6002).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A healing arts licensed professional: an MD, DO, chiropractor, podiatrist, optometrist, PA, ARNP, physical therapist or Christian Science practitioner. They complete the Healing Arts Licensed Professional's Statement and mark the disability as temporary or permanent. Rubber-stamp signatures are not accepted, and disabled plates are issued only for a permanent disability. The applicant takes the form to the county treasurer's motor vehicle office.
Within the last 90 days. After a loss or alteration of consciousness, the exam must also be at least 6 months after the last episode. A physician, APRN, PA or psychologist completes every section after the patient's General Information and Release, recommends restrictions or Medical Advisory Board review, and returns it to the Medical/Vision Unit. The same form is used to remove restrictions requested earlier.
No. Kansas law (K.S.A. 72-7119) requires a written release from a physician, MD or DO, before a student returns to full participation. The KSHSAA Concussion Return to Play form is optional: the athletic trainer records the steps, and the physician signs the release before steps 4 to 6. Any health care provider can complete the separate Return to Learn form for classroom accommodations.
No. The Kansas Division of Workers Compensation has no state physician report or work-status form, so treating physicians send narrative reports. The one clinical form is K-WC-R 87-7, the Medical Management Closure Report, which a registered medical management vendor, usually a nurse case manager, files with the Division. It states why the file is closing and certifies that the job is within the worker's restrictions.