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Provider Relations Forms

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Form Description Last Revision Date
Adult Day Health Care Attending Physician Statement May 2009
Adjustment and Void Request Form December 2020
Cash Refund Documentation March 2020
Census Cover Sheet
Instructions
July 2010
CMS1500 Crossover Coding Form Nov. 2012
EOB Codes and Descriptions August 2022
Licensed Bed Summary June 2005
Medicaid Reserved Bed Days Q and A July 2010
NDC Frequently Asked Questions
Provider Inquiry Form August 2018
TPL Lead Form December 2020
MAP 10 Waiver Services Physician's Recommendation June 2015
MAP 23 HCB Waiver Services Selection of Provider Form
July 2005
MAP 26 ABI Program Application Sept. 2010
MAP 34 Home Health Agency Certification for Dual Eligibles April 2009
MAP 95 Request for Equipment Form June 2007
MAP 109 Plan of Care/Prior Authorization for Waiver Services
Plan of Care/Prior Authorization for Waiver Services - PaperSign
July 2008
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 Aug. 2021
MAP 250 Consent to Sterilization April 2022
MAP 251 Hysterectomy Consent Form Oct 2010
MAP 350 LTC Facilities and HCB Program Certification Form July 2021
MAP 351 Medicaid Waiver Assessment April 2020
MAP 374 Election of Medicaid Hospice Benefits Dec. 2011
MAP 375 Revocation of Medicaid Hospice Benefits Dec. 2011
MAP 376 Change of Hospice Providers Dec. 2011
MAP 377 Physician's Certification for Medicaid Hospice Benefit Recertification Statement for 60-Day Period Dec. 2011
MAP 378 Termination of Medicaid Hospice Benefits Dec. 2011
MAP 379 Representative Statement for Election of Hospice Benefits Dec. 2011
MAP 383 Other Hospitalization Form Nov. 2022
MAP 384 Hospice Drug Form Nov. 2022
MAP 397 Hospice - Other Services Statement Form Dec. 2011
MAP 403 Hospice Patient Status Change Dec. 2011
MAP 409 Pre-Admission Screening and Resident Review(PASRR) Nursing Facility Ientification Screen (LEVEL I) February 2018
MAP 417 KY Application for Nurse Aide Registration June 2005
MAP 418 Medicaid Home and Community Bases Services Fact Sheet July 2009
Map 524 Medicaid Nursing Facility (NF) Services
Nov. 2011
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 August 2000
MAP 2000 Initiation/Termination of Consumer Directed Option (CDO)
Initiation/Termination of Consumer Directed Option(CDO) - PaperSign
July 2008
MAP 4092 Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Service September 2015
MAP 4093 Provisional Admission To A Nursing Facility March 2007
MAP 4094 Notification of Intent To Refer For LEVEL II PASRR March 2007
MAP 4095 PASRR Significant Change/Discharge Data June 2011
MAP 4100A Acquired Brain injury Waiver Program Provider Information and Services April 2009
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 Nov. 2006
OMB 0937-0166 Sterilization Consent - Spanish Nov. 2006

Last Updated 5/15/2019 
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