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Get Ky Map-347 2009-2025
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How to fill out the KY MAP-347 online
Filling out the KY MAP-347 form online can streamline the process of authorizing payment from the Kentucky Medicaid Program for professional services. This guide provides clear instructions for each section of the form, ensuring users of all backgrounds can complete it with ease.
Follow the steps to successfully complete the KY MAP-347 form online.
- Click the ‘Get Form’ button to access the form and open it in the online editor.
- In the first section, enter your full name as the licensed professional providing services.
- Input your Medicaid provider number in the designated field.
- Fill in the name of the clinic, corporation, or facility with which you have a contractual agreement.
- Provide the full street address or P.O. Box number, along with the city, state, and zip code for the facility.
- Indicate your authorization for payment, including any Medicaid/Medicare cross-overs to the specified clinic or facility.
- Acknowledge that you will not bill the Kentucky Medicaid Program directly for services covered in your agreement.
- Complete the necessary identification numbers: your Social Security Number, NPI, and the Kentucky Medicaid Provider Number of the facility.
- Enter the Federal Employer Identification Number of the facility where applicable.
- Document the date when the contractual agreement becomes effective.
- Sign the form to confirm your authorization, and date your signature.
- A witness must then sign and date the form in the provided areas.
- Once all fields are completed, save your changes. You have the option to download, print, or share the completed form as needed.
Complete your KY MAP-347 form online today to ensure timely processing of your Medicaid payments.
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In Kentucky, the income limit to qualify for Medicaid varies depending on your household size and specific programs. Generally, for many categories, the income limit is around 138% of the Federal Poverty Level. To find out more about how this relates to your eligibility, you can refer to the KY MAP-347 or consult with a qualified professional.
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