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  • Passport Prior Authorization Form

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Bject to all privacy and security regulations under HIPAA Patient s Name Member ID# Address Apt # or Suite # City State Phone Number Zip Code Weight - - Date of Birth (MM/DD/YY) lbs kgs Physician s Name / DEA # (with X ) Address / Apt # or Suite # City State Zip Code Contact Person Contact Person Phone Number DRUG REQUESTED (Name): Contact Person Fax Number Dose: 2mg 8mg Sig: Number of Tablets: QUANTITY: Times Per Day: ICD-9 DIAGN.

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Preparing documents electronically is not only time-saving but also gives an opportunity to edit the sample according to your demands. If you’re about to manage the Passport Prior Authorization Form, consider completing it with our extensive online editing tools. Whether you make a typo or enter the requested data into the wrong area, you can easily make adjustments to the form without the need to restart it from the beginning as during manual fill-out. In addition to that, you can point out the essential data in your document by highlighting specific pieces of content with colors, underlining them, or circling them.

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Enroll as a Medicaid Provider If you want to enroll as a Kentucky Medicaid provider and are not assigned to an MCO or choose not to participate in an MCO (fee-for-service provider), you must submit an application online using the Kentucky Medicaid Partner Portal.

To be eligible to receive Passport Health Plan by Molina Healthcare benefits, you must be enrolled with the Kentucky Medicaid program. To find out if you are eligible you can fill out an application online at kynect.ky.gov.

To change your managed care organization, call toll free (855) 446-1245 or (800) 635-2570 from 8 a.m. to 6 p.m. Eastern time to speak with a Medicaid services representative or go online to the kynect website. All plan changes made during open enrollment will take effect on Jan. 1, 2023.

​​​​​​​​​​​​​​​​​​​​​​Medicaid provides medical assistance to eligible low-income Kentuckians. Use the links below to learn more about some available programs and services. If members have any questions, please contact Member Services toll-free at (800) 635-2570.

Our enrollees get dental, hearing, medical, and vision coverage, and prescription drug and behavioral health benefits.

By faxing your request to 800-540-2406.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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