Transcription of MAP-811 Provider Application Instructions - KYMMIS
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MAP-811 Provider Application Instructions - KYMMIS
Revised 2/2004 MAP-811 Application Instructions MAP-811 . Provider Application Instructions Enrollment Block: If applying for a Kentucky Medicaid number for the first time, check first block. If re-enrolling as a Kentucky Medicaid number, check second block and enter your eight(8) digit Provider number in number 1. If a change in Federal Tax Identification number (FEIN) has occurred, check third block. If applicant has been excluded from Medicare/Medicaid by Federal, State, or court sanction please declare I am enrolling as a reinstatement , check fourth block. Section A: Administrative Information Field # Description 1 If a Medicaid Provider number has already been assigned to this entity, please enter.
Revised 2/2004 MAP-811 Application Instructions 1 MAP-811 Provider Application Instructions Enrollment Block: • If applying for a Kentucky Medicaid number for the first time, check first block.
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