Provider Relations Forms

Form	Description	Last Revision Date
	Adult Day Health Care Attending Physician Statement	May 2009
	Adjustment and Claim Credit Request	March 2018
	Cash Refund Documentation	March 2020
	Census Cover Sheet Instructions	July 2010
	CMS1500 Crossover Coding Form	Nov. 2012
	EOB Codes and Descriptions	March 2019
	Licensed Bed Summary	June 2005
	Medicaid Reserved Bed Days Q and A	July 2010
	NDC Frequently Asked Questions
	Provider Inquiry Form	Aug. 2018
	TPL Lead Form	Jan. 2011
MAP 10	Waiver Services Physician's Recommendation
Aug. 2010
MAP 23	HCB Waiver Services Selection of Provider Form and Instructions
July 2005
MAP 24	Memorandum from DCBS	August 2008
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	Sept. 2010
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 Certification for Disposable Medical Supplies
April 2009
MAP 250	Consent to Sterilization
May 2019
MAP 251	Hysterectomy Consent Form
Oct 2010
MAP 350	LTC Facilities and HCB Program Certification Form
April 2019
MAP 351	Medicaid Waiver Assessment
July 2008
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
Dec. 2011
MAP 384	Hospice Drug Form
Jan. 2012
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)
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
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