Provider Relations Forms

Form	Description	Last Revision Date
	NDC Detail Attachment Form	December 2007
	Adjustment and Claim Credit Request	June 2005
	Cash Refund Documentation	June 2005
	EOB Codes and Descriptions	June 2005
	Licensed Bed Summary	June 2005
	Provider Authorization for Messenger Pick-up of Medicaid Checks	June 2005
	TPL Lead Form	June 2005
	Voice Response Conversion Chart	June 2005
MAP 10	Home and Community Based Services Waiver
June 2005
MAP 10H	Homecare Waiver
June 2005
MAP 10P	Personal Care Assistance Waiver Servies	June 2005
MAP 24	Memorandum from DCBS	June 2005
MAP 24B	Brain Injury Waiver Admission/Discharge	June 2005
MAP 34	Home Health Agency Certification
June 2005
MAP 95	Request for Equipment
June 2005
MAP 235	Certification for Induced Abortion or Miscarriage
June 2005
MAP 236	Certification for Induced Premature Birth
June 2005
MAP 248	Certification for Disposable Medical Supplies
June 2005
MAP 250	Consent to Sterilization
June 2005
MAP 251	Hysterectomy Consent Form
June 2005
MAP 252	Forms Reorder Form
June 2005
MAP 350	LTC Facilities and HCB Program Certification Form
June 2005
MAP 374	Election of Medicaid Hospice Benefit
June 2005
MAP 375	Revocation of Medicaid Hospice Benefits
June 2005
MAP 376	Change of Hospice Providers
June 2005
MAP 378	Termination of Medicaid Hospice Benefits
September 1992
MAP 379	Representative Statems for Election of Hospice Benefits
June 2005
MAP 383	Other Hospitilization Statement
June 2005
MAP 384	Hospice Drug Form
June 2005
MAP 397	Other Services Statement
June 2005
MAP 403	Hospice Patient Status Change
June 2005
MAP 409	Preadmission Screening and Resident Review(PASRR) Nursing Facility Identification Screen
June 2005
MAP 417	KY Application for Nurse Aide Registration
June 2005
MAP 418	Medicaid Home and Community Bases Services Fact Sheet
June 2005
MAP 586	Assurance of Case Management Services Certification Form
June 2005
MAP 720	Authorization for Emergency Ambulance Services
June 2005
MAP 1021	Adult Day Health Care Payment Determination
June 2005
MAP 4092	Exempted Hospital Discharge Physician Cert. of Need for NF Sves.
June 2005
MAP 4093	Provisional Admission to a Nursing Facility
June 2005
MAP 4094	Notification of Intent to Refer For Level II PASRR	June 2005
MAP 4095	Significant Change in Conditional Referral
June 2005
MAP 4096	Acquired Brain Injury Waiver Svcs - Memorandum of Understanding
June 2005
MAP 4097	HBC Acquired Brain Injury Plan of Care
June 2005
MAP 4098	Acquired Brain Injury Plan of Care Modification
June 2005
MAP 4099	Acquired Brain Injury Waiver Svcs Prog Physician Certification Form	June 2005
MAP 4100H	Homecare Waiver Services Provider Information and Services	June 2005
MAP 4100P	Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Svcs
June 2005
MAP 4105	Application for Transfer Trauma Exemption
June 2005
MAP 4200	Approval for Nursing Facility Placement and Waiver Program
June 2005
OMB 0937-0166	Sterilization Consent
June 2005