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MAP-811 Addendum E 6/09 DEPARTMENT FOR MEDICAID SERVICES DIRECT DEPOSIT AUTHORIZATION/CANCELLATION FORM Complete the following provider information Provider Name Provider Number NPI National Provider Identifier Address City State Zip Telephone Number Contact Name New Enrollment Institution or Account Change Bank Name Branch or correspondent Bank if applicable Transit/ABA Number Account Number Account Type select one Checking Savings I the undersi.

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Kentucky Medicaid/KCHIP is a state and federal program. It is authorized by Title XIX of the Social Security Act. Kentucky Medicaid/KCHIP provides health coverage for eligible low-income residents.

Department for Medicaid Services - Cabinet for Health and Family Services.

These are the main income rules for income-based Medicaid: If your family's income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.

If you have any questions regarding your enrollment, please call Kentucky Medicaid toll free at (877) 838-5085. A provider enrollment specialist will be available to help you between the hours of 8 am and 4:30 pm, EST, Monday through Friday.

Enrolling New Kentucky Medicaid Providers Review the provider type summary for your provider type to understand the documentation required to enroll. Review the training resources to help navigate the KY MPPA. Download multifactor authentication software. Create an account and start an application on the KY MPPA.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232