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Get Map 811 Non Credentialed Application Instructions Form

In the program is not a guarantee; therefore, providing services to Kentucky Medicaid members prior to your effective date is at your own financial risk. Did you: Complete all questions. Questions not applicable should be completed with N/A . (Applications will be rejected for any questions left blank.) Sign and date signature page 6. Only original blue ink signatures are accepted. Copied or stamped signatures are not accepted. Attach appropriate licenses and/or certifications.

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