Provider Relations Forms

Form	Description	Last Revision Date
	Adult Day Health Care Attending Physician Statement	May 2009
	CMS1500 Crossover Coding Form	June 2008
	NDC Detail Attachment Form	March 2009
	NDC Frequently Asked Questions
	Adjustment and Claim Credit Request	Nov. 2009
	Cash Refund Documentation	Nov. 2009
	EOB Codes and Descriptions	June 2005
	Licensed Bed Summary	June 2005
	Provider Inquiry Form	Nov. 2009
	TPL Lead Form	Nov. 2009
MAP 10	Home and Community Based Services Waiver
June 2005
MAP 24	Memorandum from DCBS	June 2005
MAP 24B	Brain Injury Waiver Admission/Discharge	June 2005
MAP 24C	Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program	July 2008
MAP 26	ABI Program Application	July 2008
MAP 34	Instructions for Completion of the MAP 34-PDF doc Home Health Agency Certification-word doc
April 2009
MAP 95	Request for Equipment Form
June 2007
MAP 109	Plan of Care/Prior Authorization for Waiver Services
July 2008
MAP 235	Certification for Induced Abortion or Miscarriage
June 2005
MAP 236	Certification for Induced Premature Birth
June 2005
MAP 248	Instructions for Completion of the MAP 248-PDF doc Certification for Disposable Medical Supplies-word doc
April 2009
MAP 250	Consent to Sterilization
June 2005
MAP 251	Hysterectomy Consent Form
June 2005
MAP 350	LTC Facilities and HCB Program Certification Form
June 2005
MAP 350 NF	MAP 350 NF Instruct 2009 MAP 350 NF Form 2009
March 2009
MAP 351	Medicaid Waiver Assessment
March 2007
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
Sept. 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	Pre-Admission Screening and Resident Review(PASRR) Nursing Facility Ientification Screen (LEVEL I)
March 2007
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
August 2000
MAP 2000	Initiation/Termination of Consumer Directed Option (CDO)
July 2008
MAP 4092	Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Service
March 2007
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
March 2007
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
November 2006
OMB 0937-0166	Sterilization Consent - Spanish
November 2006