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. Otherwise leave blank. 2 Enter License/Certificate number for the applicant. 3 Enter type of Provider . EXAMPLE: physician; hospital; pharmacy;. etc. Mark appropriate block for profit or non-profit. 4 Name of individual Provider , practice or facility enrolling- mark the appropriate block.

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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  Applications, Kentucky, Instructions, Medicaid, Provider, Map 811 provider application instructions, Kymmis, Kentucky medicaid

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