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 |
February 2023 |
|
Crossover Coding Sheet Instructions |
|
|
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
| July 2023 |
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 |