AKAA Provider Forms Request

Please limit the quantity of forms and envelopes requested to an amount that would be used in a 3-month period.

Provider Name
Provider Number
	(Please enter your complete Medicaid assigned number)
Street Address
	(Cannot deliver to post office box)
City
State
Zip
Attention
Phone
E-mail Address

Enter the quantity of the forms being requested.
Quantity	All Kids/FamilyCare Form Number
	KC 3738MC All Kids/FamilyCare Application Activity Log
	KC 3739MC/MCS Notice Regarding Interest in All Kids Program Letter
	KC 11081 All Kids Prepaid Business Reply Envelope
	KC 3740MC All Kids Application Transmittal Sheet
	KC 3710 All Kids Application Fax Transmittal Sheet
	KC 2790KCA Self-Employment Record (English)
	KC 2790KCAS Self-Employment Record (Spanish)
	KC 3800 Informed Choice Brochure (English)
	KC 3800S Informed Choice Brochure (Spanish)
	HFS 243C Request for Medical Benefits for Another Family Member(s) (English)
	HFS 243CS Request for Medical Benefits for Another Family Member(s) (Spanish)
	KC 2378MC All Kids/FamilyCare Application (English)
	KC 2378MCS All Kids/FamilyCare Application (Spanish)
	KC 243N Request to Add a Newborn
	HFS 3863 Questions & Answers About Immigration & Public Charge
Quantity	Additional Forms Needed, Not Listed Above