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Kentucky Medical Management Information System (KYMMIS)

Provider Relations Forms

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Provider Relations Forms are displayed in Adobe Acrobat formats.

Form	Description	Last Revision Date
	Adult Day Health Care Attending Physician Statement	May 2009
	Adjustment and Void Request Form	December 2020
	Cash Refund Documentation	March 2020
	Census Cover Sheet Instructions	July 2010
	CMS1500 Crossover Coding Form	February 2023
	Crossover Coding Sheet Instructions
	EOB Codes and Descriptions	August 2022
	Licensed Bed Summary	June 2005
	Medicaid Reserved Bed Days Q and A	July 2010
	NDC Frequently Asked Questions
	Provider Inquiry Form	August 2018
	TPL Lead Form	December 2020
MAP 10	Waiver Services Physician's Recommendation	June 2015
MAP 23	HCB Waiver Services Selection of Provider Form	July 2005
MAP 26	ABI Program Application	Sept. 2010
MAP 34	Home Health Agency Certification for Dual Eligibles	April 2009
MAP 95	Request for Equipment Form	June 2007
MAP 109	Plan of Care/Prior Authorization for Waiver Services Plan of Care/Prior Authorization for Waiver Services - PaperSign	July 2008
MAP 235	Certification for Induced Abortion or Miscarriage	June 2005
MAP 236	Certification for Induced Premature Birth	June 2005
MAP 248	Certification for Disposable Medical Supplies	Aug. 2021
MAP 250	Consent to Sterilization	April 2022
MAP 251	Hysterectomy Consent Form	July 2023
MAP 350	LTC Facilities and HCB Program Certification Form	July 2021
MAP 351	Medicaid Waiver Assessment	April 2020
MAP 374	Election of Medicaid Hospice Benefits	Dec. 2011
MAP 375	Revocation of Medicaid Hospice Benefits	Dec. 2011
MAP 376	Change of Hospice Providers	Dec. 2011
MAP 377	Physician's Certification for Medicaid Hospice Benefit Recertification Statement for 60-Day Period	Dec. 2011
MAP 378	Termination of Medicaid Hospice Benefits	Dec. 2011
MAP 379	Representative Statement for Election of Hospice Benefits	Dec. 2011
MAP 383	Other Hospitalization Form	Nov. 2022
MAP 384	Hospice Drug Form	Nov. 2022
MAP 397	Hospice - Other Services Statement Form	Dec. 2011
MAP 403	Hospice Patient Status Change	Dec. 2011
MAP 409	Pre-Admission Screening and Resident Review(PASRR) Nursing Facility Ientification Screen (LEVEL I)	February 2018
MAP 417	KY Application for Nurse Aide Registration	June 2005
MAP 418	Medicaid Home and Community Bases Services Fact Sheet	July 2009
Map 524	Medicaid Nursing Facility (NF) Services	Nov. 2011
MAP 586	Assurance of Case Management Services Certification Form	June 2005
MAP 720	Authorization for Emergency Ambulance Services	June 2005
MAP 1021	Adult Day Health Care Payment Determination	August 2000
MAP 2000	Initiation/Termination of Consumer Directed Option (CDO) Initiation/Termination of Consumer Directed Option(CDO) - PaperSign	July 2008
MAP 4092	Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Service	September 2015
MAP 4093	Provisional Admission To A Nursing Facility	March 2007
MAP 4094	Notification of Intent To Refer For LEVEL II PASRR	March 2007
MAP 4095	PASRR Significant Change/Discharge Data	June 2011
MAP 4100A	Acquired Brain injury Waiver Program Provider Information and Services	April 2009
MAP 4100P	Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Svcs	June 2005
MAP 4105	Application for Transfer Trauma Exemption	June 2005
MAP 4200	Approval for Nursing Facility Placement and Waiver Program	June 2005
OMB 0937-0166	Sterilization Consent	Nov. 2006
OMB 0937-0166	Sterilization Consent - Spanish	Nov. 2006

Last Updated 5/15/2019

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