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Forms

Welcome to the Kentucky Department of Medicaid Services Provider Enrollment Forms webpage.

If you are a new provider, refer to the enrollment forms listed below.

If you are an existing provider and need to make changes, refer to the maintenance forms listed below.

Revised Forms

As of Apr. 1, 20117, only the MAP- 811 (Enrollment) ( Rev. Jan 2017) and the MAP-900 (Revalidation) (Rev. Jan. 2017) will be accepted.

Attention Providers

(May 24, 2016) - Please see the updated information below regarding changes to the MAP-347 and the MAP-529. Please note this change will apply to new submissions of these forms beginning June 1, 2016.

MAP-347, the Statement for Authorization of Payment, Group Linkage Section form has been updated. The old form will be accepted up to May 31, 2016. Beginning June 1, 2016, the new MAP-347 will be required. Any MAP-347 submitted after May 31, 2016 on the old form will be returned for updating. The distinguishing factor to recognize you are using the correct form is [MAP-347, Rev. May 2016] in the top left corner of the form.

MAP-529, KY Medicaid Change of Information Form has been updated. The old form will be accepted up to May 31, 2016. Beginning June 1, 2016, the new MAP-529 will be required. Any MAP-529 submitted after May 31, 2016 on the old form will be returned for updating. The distinguishing factor to recognize you are using the correct form is [MAP-529, Rev. May 2016] in the top left corner of the form.

If you have any questions, please either email or call us at 1-877-838-5085.

Enrollment Forms
Maintenance Forms

 

Contact Information
 

Kentucky Department for Medicaid Services
Provider Enrollment
P.O. Box 2110
Frankfort, KY 40602
Toll free: 877-838-5085
Monday to Friday
8 a.m. - 5:00 p.m. EST

Email

For questions regarding this website, e-mail the CHFS DMS Webmaster

 

Last Updated 5/24/2017