Get Map 811 Addendum E

The Map 811 Addendum E is a vital document for managing direct deposits efficiently in the Medicaid services system. This guide provides user-friendly instructions to assist you in completing the form online smoothly and correctly.

Follow the steps to fill out the Map 811 Addendum E

1. Press the ‘Get Form’ button to access the Map 811 Addendum E and open it in your preferred online editor.
2. In the 'Provider Information' section, enter the complete legal name of the institution or individual provider.
3. Next, provide the Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN), followed by the National Provider Identifier (NPI) and Kentucky Medicaid Provider Number.
4. In the 'Provider Contact Information' section, fill in the contact name of the person managing Electronic Funds Transfer (EFT) issues, their title, telephone number, and email address.
5. Move to the 'Financial Institution Information' section where you will input the official name of your financial institution and their routing number.
6. Select the type of account from ‘Checking’ or ‘Savings’ and continue by entering your provider’s account number with the financial institution.
7. Indicate the reason for submission by checking the appropriate box for New Enrollment, Change Enrollment, or Cancel Enrollment.
8. If applicable, indicate whether you are including a voided check or a bank letter with your submission.
9. Review your entries for accuracy and then provide your authorized signature and date at the bottom of the form.
10. Once you have completed all necessary fields, save your changes, download a copy of the form, or choose to print or share it as needed.

Complete your Map 811 Addendum E online today for efficient Medicaid direct deposits.