Ksbha form 2026

1. Click ‘Get Form’ to open the ksbha form in the editor.
2. Begin by selecting the appropriate agency receiving the report. Check the box next to Kansas Board of Healing Arts, Nursing, Pharmacy, Dental Board, or Other.
3. Indicate whether you are submitting the report as an Individual or Facility. Fill in your name, telephone number, address, and email if you select Individual. For Facility submissions, provide the facility name and CCN#.
4. Complete the Incident Identification section by entering the IRN (if applicable), date of incident, medical record number (if known), patient name, date of birth, and location of incident.
5. List any licensees involved in the incident along with their details. Describe the incident thoroughly in the provided space or attach a separate sheet if necessary.
6. Detail any education, correctional actions taken regarding this incident and include additional records related to it if available.
7. Select the type of incident from the provided options and ensure all required fields are filled before submitting your report.

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