Get Ky Medicaid Administrator Change Request Form

The KY Medicaid Administrator Change Request Form allows users to request changes to the administrator settings of the KY Health Choices website. This guide provides step-by-step instructions on how to accurately fill out the form online.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by printing your name as the new administrator in the designated field. This identifies who is requesting the change.
3. Provide the current administrator's information, including the Kentucky Medicaid provider ID number, logon/username, and any other required details.
4. Fill in the replacement administrator's information. This section may mirror the current administrator's details if they are the same.
5. Enter the new administrator’s name, email address, contact phone number, and mailing address in the respective fields.
6. Attach a copy of your driver’s license to the form. This documentation is necessary for account validation and to prevent fraudulent requests.
7. Select the reason for the update by checking the appropriate box. Common reasons include employee departure, change of email address, or failure to change the security question.
8. Once all fields are completed and reviewed for accuracy, you can submit the form via fax at 502-209-3242 or email it to KY_EDI_Helpdesk@dxc.com.
9. Finally, ensure any completed forms are saved, downloaded, printed, or shared as necessary for your records.

Start completing your KY Medicaid Administrator Change Request Form online today for a seamless transition.