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 has a flyer that provides basic information about the program to new applicants. KHC recognizes that many times clients can be overwhelmed when they apply for the program. This flyer aims to help them 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)

Kidney Health Care: Guide to your KHC Benefits (PDF in English and Spanish)