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Get Ky Map-811 2010
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How to fill out the KY Map-811 online
Filling out the KY Map-811 form is an essential step for individuals looking to participate as providers in the Kentucky Medicaid program. This guide provides clear and comprehensive instructions for effectively completing the online form.
Follow the steps to successfully complete the KY Map-811 form.
- Click ‘Get Form’ button to access the form and open it in your preferred editor.
- Begin with Section A: Administrative Information. Here, specify if you are a new provider, re-applicating, or indicating a change in ownership. Fill out your Kentucky Medicaid provider number, name, provider type, primary practice county, and service type.
- Continue by entering the desired effective date for your enrollment, your National Provider Identifier (NPI), and Taxonomy Code(s). Include any necessary documentation for verification.
- Proceed to Section B: Disclosure of Ownership and Control Interest. Provide details of ownership interests and any previous Medicaid provider numbers. Indicate changes in ownership or management if applicable.
- Complete Section C: Tax Structure by checking the appropriate box for your tax classification and providing required information based on your entity type.
- Finalize your application by ensuring all applicable sections are filled out. Use 'N/A' for any questions that do not pertain to you. Pay special attention to the signature section; your signature must be in blue ink and clearly printed.
- Once you are satisfied with the completed form, save your changes. You can download, print, or share the form as needed before mailing it to the designated address for Kentucky Medicaid.
Complete your KY Map-811 form online today to secure your enrollment in the Kentucky Medicaid program.
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To obtain a provider number for Medicaid in Kentucky, you must first register as a Medicaid provider with the state. After your application is approved, you will be assigned a unique provider number. Accessing the KY Map-811 resources on USLegalForms can assist you with all requirements and steps in obtaining your provider number efficiently.
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