Kansas Health Care Stabilization Fund
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E-Form Notice of Basic Coverage

Welcome to the online compliance form portal.

This online form will allow you to enter information that is required of all medical practitioners for annual compliance within the State of Kansas.

The on-line electronic compliance form normally works well with most web browsers.
However, please keep the following in mind:

  1. The 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.
  2. 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 to the provider’s record that you are entering.
Some of the fields are absolutely required for all health care providers and the form cannot be submitted until those required fields contain information.

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.

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 pdf format.

It is extremely important that the correct license number is entered in the first field.
If the health care provider does not reside in the United States or Puerto Rico, enter the most accurate address possible in the “Street address” field and then enter the city, the state or province, and the country in the “City” field. In the “State” field select “Non-USA” (the last option) and if there is no zip code, enter the number 0 in the Zip field.

For basic field-by-field instructions, please download and print the following document:  E-Form Basic Instructions

For detailed 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: HCSF Forms and Supporting Documents | Kansas Health Care Stabilization Fund

To access the compliance e-form, select the following link: Compliance E-Form

For Online Payments
Please be aware – Due to recent changes made by Kansas.gov;
1.  The KanPay option cannot be used with Internet Explorer.  You must use an alternative browser, such as Microsoft Edge or Google Chrome, to complete the payment process.
2.  The KanPay option only allows 10 entries per transaction.  If you need to pay for more than 10 providers, you must create/complete additional transactions on the KanPay site.

To access the on-line payment web, select the following link: KanPay

To download the mail-in payment form, select:  HCSF Multi Surcharge Form