Forms

Kidney Health Care Client Forms

• KHC Client Application Checklist (PDF)
• Form 3035 - KHC Client Application
• Form 3057 - KHC Physician Assessment
• CMS 2728 - ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration
• Direct Deposit Authorization (PDF)

Kidney Health Care Travel Forms

• Form 3093, KHC Travel Claim for Home Dialysis and Kidney Transplant Patients

Kidney Health Care Insurance Update Forms

• KHC Medicare Part D Update Form (PDF)
• KHC Insurance Update Form (PDF)

Kidney Health Care Publications

Kidney Health Care recognizes that many times clients can be overwhelmed when they apply for the program. These flyers aim to help them better understand the program’s role in managing their kidney disease.

• What to Know After Applying to KHC (PDF in English)
• What to Know After Applying to KHC (PDF in Spanish)