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.

• Map 347 - Statement for Authorization of Payment
• MAP 572A - Private Auto Provider
• Map 572B - Foster Parent Provider Agreement
• MAP-612 - Statement for Authorization of Payment (Physician Assistant)
• MAP-811 Non Credentialed (with MAP-811 Addendum E)
• MAP-811 Individual (with MAP- 811 Addendum E) and 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

• Request to Add FEIN to File Form
• 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-358C - KenPAC Provider Change of Information (New practitioners at the site)
• MAP-358D - KenPAC Provider Change of Information (Change in quota)
• MAP-380 - Agreement Between the Kentucky Department for Medicaid Services And the Kentucky Medicaid Provider
• 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
• MAP-4100A -Acquired Brain Injury Waiver Program Provider Information and Services
• Supports for Community Living Statement of Services to Be Provided
• 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.