Forms and Publications

Client Forms

Application for Benefits Forms

An application for benefits must be submitted through a Kidney Health Care (KHC) participating outpatient dialysis facility, hospital or VA facility.

Direct Deposit Form

Did you know that you can get your travel benefits sent directly to your bank account? With direct deposit Kidney Health Care (KHC) can send your travel checks to your bank account instead of to your home. It is safe, secure and it lets you get your money back up to one week sooner.

It’s simple to do. Just follow these steps:

    1. Click Direct Deposit Authorization Form (English, 64 KB, PDF).
    2. Follow the directions on page 2. (You are the “Payee”.)
    3. Print out the form. (You can do this either before or after you fill it out.)
    4. Mail the form to

      DSHS Claims Unit
      Mail Code 1940
      PO Box 149347
      Austin, TX  78714-9347

If you have questions, please call 1-800-222-3986. 

Travel Forms

IMPORTANT: KHC does not accept faxed Transportation Claims. Please do not fax the Home and Transplant Travel Claim form to KHC. KHC only accepts this form by mail.

The Kidney Health Care (KHC) Program has a new form for home dialysis and kidney transplant clients who need to claim travel to medical visits. For your convenience, there are two editions of the form at your disposal:

  • This form can be completed online, and then printed out. You must sign the printed copy and send it in. KHC can only accept forms with an original signature.
    Travel Claim Form  (KHC-3) (English, Word)
  • This form must be printed from your computer and filled out by hand. You must sign and send it in. KHC can only accept forms with an original signature.
    Travel Claim Form (KHC-3) (English, PDF)

Formularios para reclamar viajes

IMPORTANTE: KHC no acepta los formularios para reclamar viajes (KHC-3A) que se mandan por fax. Favor de no mandar ese formulario a KHC. KHC solo acepta los formularios KHC-3A originales mandados por correo.    

El Programa de Cuidado de la Salud del Riñón (KHC) tiene un nuevo formulario disponible a sus clientes que hacen diálisis en casa o que recibieron un trasplante de riñón para reclamar el costo de sus viajes a consultas médicas. Para su comodidad, hay dos versiones del formulario a su disposición:

  • Esta versión puede rellenarse en el Internet y luego imprimirse. Se necesita firmar el formulario impreso y enviarlo por correo. Solo se aceptan formularios con firmas originales.
    Formulario para reclamar viajes (KHC-3A) (Spanish, Word)
  • Esta versión ha de imprimirse y rellenarse a mano. Se necesita firmar el formulario y enviarlo por correo. Solo se aceptan formularios con firmas originales.
    Formulario para reclamar viajes(KHC-3A) (Spanish, PDF)

Information Update Forms

Notice: The Fax Cover for KHC Medicare Rx Update Form  has been replaced by the Medicare Part D Update and Insurance Update forms below. Posted 06/04/2017.

Medicare Part D Update Form

Request Medicare Rx updates, such as Medicare Rx first-time new enrollments, disenrollment letters, Client Medicare numbers, Client Medicare Part A effective date, etc. Instructions are on the form. This form and the Insurance Update Form have replaced the Fax Cover for Medicare Rx Update Form.

Download the Medicare Part D Update Form (English, 95KB, PDF) -  Revised June, 2017.

Insurance Update Form

Request insurance updates such as type of insurance, policy identification number, group number, policy holder information, effective date of coverage, etc. Instructions are on the form. This form and the Medicare Part D Update Form have replaced the Fax Cover for Medicare Rx Update Form.

Download the Insurance Update Form (English, 52KB, PDF) - Revised April, 2017

KHC Status Update Form

Submit monthly reports on updates to KHC clients’ status, such as address change, modality, termination of services, etc. Instructions to complete the form are listed below.

Download instructions in Word (40KB). Download instructions in PDF (English, 40KB). - Revised June, 2017.

Download KHC Status Update Form (English, 195 KB, PDF) - Revised February, 2017.

KHC Publications

Flier for New Applicants and Clients

Kidney Health Care now has a flier that provides basic information about KHC to new applicants! KHC recognizes that many times clients can be overwhelmed with everything that is happening when they apply to KHC. This flier aims to help them understand the program’s role in managing their kidney disease.

Provider Manual

Contact KHC by email or by phone at 1-800-222-3986.

Last updated August 7, 2017