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Provider Relations Forms

Contact Information
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Provider Letters
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Provider Billing Instructions
KY Health Net user manuals

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
July 2010

CMS1500 Crossover Coding Form Nov. 2012

EOB Codes and Descriptions September 2021

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 and
July 2005
MAP 26 ABI Program Application Sept. 2010
MAP 34 Instructions for Completion of the MAP 34-PDF doc
Home Health Agency Certification-word doc
April 2009
MAP 95 Request for Equipment Form
June 2007
MAP 109 Plan of Care/Prior Authorization for Waiver Services
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
May 2019
MAP 251 Hysterectomy Consent Form
Oct 2010
MAP 350 LTC Facilities and HCB Program Certification Form
April 2019
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
Dec. 2011
MAP 384 Hospice Drug Form
Jan. 2012
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)
July 2008
MAP 4092 Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Service
March 2007
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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