Forms

Enrollment Forms

• Map 347 - Statement for Authorization of Payment
• MAP 527 A - Private Auto Provider
• Map 527 B - Foster Parent Provider Agreement
• Map 612 - Statement for Authorization of Payment (Physician Assistant)
• Non-Credentialed Provider Application (with MAP 811 Addendum E)
• Credentialed Individual Provider Application (You must complete both documents below.)
  • Map 811 (with MAP 811 Addendum E) 
  • KAPER-1
  • KAPER-1 Code Lists (Refer to these code lists as you complete the KAPER-1).
• Map 811 Addendum D  - KenPAC Primary Care Case Management Agreement
• MAP 811 Addendum E - Direct Deposit Authorization/Cancellation Form
• MAP 814 - EPSDT Special Services Short Form
• Map 4100 - Acquired Brain Injury Waiver Program Provider Information and Services
• Supports for Community Living Statement of Services to Be Provided
• Dental Credentialing Form
• Multiple NPI Registration Form

Maintenance Forms

• MAP 246 - Agreement between the KY Medicaid Program and Electronic Billing Agency
• Map 347 - Statement for Authorization of Payment
• Map 358A - KenPac Provider Change of Information (Add or close a KenPac provider site
• Map 358 B - KenPAC Provider Change of Information (Address or 24-hour phone number change)
• MAP 358 C - KenPAC Provider Change of Information (New practitioners at the site)
• MAP 358 D - KenPAC Provider Change of Information (Change in quota)
• Map 380 - Provider Agreement Electronic Media Addendum
• MAP 529 -  Kentucky Medicaid Change Information Form
• Map 612 - Statement for Authorization of Payment (Physician assistant)
• Map 4100 - Acquired Brain Injury Waiver Program Provider Information and Services
• Supports for Community Living Statement of Services to Be Provided
• Prescribing Provider Form
• Locum Tenens Registration Form
• Annual Disclosure of Ownership (ADO) Form

Note:  MAP 600 is no longer needed due to implementation of mandatory use of the NPI.  Please ensure that your NPI is on file with Provider Enrollment.