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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 mainintenance forms listed below.

Attention Providers - MAP-811 form launch delayed

(May 5, 2015) - An April 26, 2015 letter sent to providers regarding 2015 legislative changes to provider enrollment included the statement, "In addition, effective May 1, 2015, all applications must be submitted on the revised MAP-811 in order to be processed. Otherwise, the application will be returned."

Due to technical difficulties launching the new MAP-811 form, DMS advises providers this change will not take effect until July 1, 2015. You may submit either version of the MAP 811 application until July 1, 2015.

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. - 4:30 p.m. EST

Email

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

 

Last Updated 5/5/2015
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