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.
- Application for Benefits with Addendum for Medicare Part D (English, 340K, Word)
Application for Benefits with Addendum for Medicare Part D (English, 107K, PDF)
- Application Instructions (English, 48K, PDF)
- Application Residency Documents (English, 38K, PDF)
- Verification of Social Security Number (English, 17K, PDF)
Direct Deposit Form
Did you know that you can get your travel benefits sent directly to your bank account? With direct deposit the Kidney Health Care (KHC) Program 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:
- Click Direct Deposit Authorization Form (English, 64 KB, PDF).
- Follow the directions on page 2. (You are the “Payee”.)
- Print out the form. (You can do this either before or after you fill it out.)
- Mail the form to
DSHS Claims Unit
Mail Code 1940
PO Box 149347
Austin, TX 78714-9347
If you have questions, please call KHC at 1-800-222-3986.
Flier for New Applicants
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.
In addition to downloading the flier from the KHC website, providers can order up to 50 free copies at a time from the DSHS online catalog at Forms and Literature Catalog. Here’s how:
- Type in “KHC-010” in the box labeled “Stock#/Publication#/ Catalog# (Partial or Full)”.
- Click on “Search the Catalog”.
- On the next screen, type in the quantity you want for English and Spanish versions.
- Click on “Go To Your Shopping Cart”.
- Review your order on the next screen. If it is correct, click on “Ready to Submit Order”.
- You will have to set up an account on the next screen if you don’t have one yet. It is free.
If you have trouble ordering, or need more instructions, go to Forms and Literature Catalog Help.
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 one can be completed online, and then printed out. You need to sign the printed copy and send it in. KHC can only accept forms that have an original signature.
Travel Claim Form (KHC-3) (English, Word)
- This one must be printed from your computer and filled out by hand. Be sure to sign and send it in. KHC can only accept forms that have 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. Usted necesita firmar el formulario impreso y enviarlo al programa. KHC solamente puede aceptar formularios con firmas originales.
Formulario para reclamar viajes (KHC-3A) (Spanish, 112K, Word)
- Esta versión tiene que imprimirse de su computadora y rellenarse a mano. Asegúrese de firmar el formulario y enviarlo al programa. KHC solamente puede aceptar formularios con firmas originales.
Formulario para reclamar viajes (KHC-3A) (Spanish, 40K, PDF)
Contact KHC by email