HCSF Compliance E-Form
The on-line electronic compliance form is designed such that it should open in a new window on your computer so you can refer back to these instructions if needed. It is designed for a typical computer monitor with a normal screen resolution. If you experience fragmentation of the image, it is probably because your monitor's screen resolution is too high.
The on-line electronic compliance form is designed for use by several different categories of health care providers including facilities and business entities. Therefore some of the fields may not be applicable. Please complete those fields that are pertinent. Some of the fields are absolutely required for all health care providers and the form cannot be submitted until those required fields contain information.
The key field is the Kansas license number. All licensed health care providers must enter their correct Kansas license number in this field. Those few health care providers that are not licensed by the State (for example, professional corporations and limited liability companies) may enter their federal employer identification number in the license number field.
After the license number field is completed and the user has tabbed forward, existing data on record will populate some of the fields. If any of this information has changed, please tab forward to the incorrect field, delete the existing data, and enter the correct information. If the licensee is a new health care provider with no previous compliance, all fields will be blank. It is extremely important that the correct license number is entered in the first field. For instructions regarding calculation of the correct HCSF premium surcharge, refer to the instructions for the Notice of Basic Coverage or the Non-resident Certification which may be downloaded from the forms page at this website.
The electronic compliance form has an attachment option. The user may attach supporting documents such as a certificate of insurance, but the attachment must be in a readable format such as portable document format (pdf) or tagged image format (tif). MSWord 2007 or an older version of MSWord is acceptable.
Submittal of the compliance e-form does not conclude the compliance process. The submitted form will be reviewed by HCSF staff to determine accuracy and completeness. In addition, the correct premium surcharge must be received. The premium surcharge may be mailed to the HCSF office or may be submitted electronically using the KanPay website. Please indicate in section E which option you have chosen to use for payment. If payment by mail is selected, please enclose a list of the names of those health care providers for whom payment is made with the check. A convenient spreadsheet has been designed for providing a list of health care providers. Users must have MSExcel® 97-2003 or newer in order to download and open the form.
KanPay is the same website used by a number of other state agencies to accept on-line payments. After submitting the compliance e-form, the user may navigate to the KanPay website and pay the premium surcharge using electronic funds transfer or a credit card. There is a portal fee for the on-line payment option. KanPay will not accept payments in excess of $3,499.99. Other arrangements may be made for electronic fund transfers of $3,500.00 or more by contacting the HCSF Fiscal and IT Section.
To access the compliance e-form, select the following link:Compliance E-Form
To access the on-line payment website, select the following link: KanPay
To download the mail-in payment form, select: HCSF Multi-Surcharge Form