Get Ky Map-529 2016-2025

The Kentucky Medicaid Change of Information Form (KY MAP-529) allows providers to update their information efficiently and accurately. This guide offers a step-by-step approach to completing the form online, ensuring all necessary details are provided.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the KY MAP-529 form and open it in the online editor.
2. Fill out the current existing information section. Provide the provider's name, either as an individual or entity/group, along with the provider number and NPI.
3. Enter the contact information of the person preparing the form, including their name, telephone number, and email address.
4. In the name change section, enter the new name and provide a reason for the change. Attach any required supporting documentation as indicated.
5. Complete the change of address section. List the new physical address, correspondence address, and where payments should be sent (pay-to address) with complete details.
6. If applicable, provide additional location information in the additional location section, including new physical addresses and contact details.
7. For those requesting a termination of their Kentucky Medicaid number, fill in your name, requested effective termination date, and the Medicaid number being terminated.
8. Sign the form, including the printed name and title, to authorize Kentucky Medicaid to implement the changes noted on the form.
9. Once all information is accurately completed, save your changes. You will have the option to download, print, or share the completed form as needed.

Complete your KY MAP-529 form online today to ensure your Medicaid information is current and accurate.