Forms
Access key forms for authorizations, claims, pharmacy and more.
Kentucky HEALTH
- Kentucky Medically Frail Provider Attestation (PDF)
- Kentucky Medically Frail Medical Condition Guide (PDF)
Administrative
- Abortion/Miscarriage Certification (PDF)
- Appointment of Representative (PDF)
- Delivery Notification (PDF)
- EPSDT Well Child Exam Form (PDF)
- EPSDT Well Child Exam Fillable (PDF)
- ER Medical Review Request (PDF)
- Hysterectomy Consent (PDF)
- Notice of Pregnancy Form (PDF)
- PCP Change Request Form (PDF)
- PCP Request for Transfer of Member (PDF)
- Prenatal Reward Visits Log (PDF)
- Requesting Interpreter Services Form (PDF)
- Sterilization Consent (PDF)
- WW Baseline Form (PDF)
- WW Outcome Form (PDF)
Appeals and Grievances
- Kentucky Medicaid MCO Provider Appeal Request (PDF)
- Kentucky Medicaid MCO Provider Grievance Form (PDF)
Authorizations
- Universal Prior Authorization Form (PDF)
- Universal 17-P Authorization Form (PDF)
- Delivery Notification Form (PDF)
- DME Services Authorization Request (PDF)
- Home Health Services Request (PDF)
- Inpatient Authorization Request (PDF)
- Outpatient Authorization Request (PDF)
- Medical Admission Fax Cover Letter (PDF)
- Skilled Therapy Services Authorization Request (PDF)
- Transplant Authorization Request (PDF)
- Notice of Pregnancy Form (PDF)
Behavioral Health
- Applied Behavioral Analysis for Autism Spectrum Disorder (PDF)
- ACT Services Request Form (PDF)
- Detox and Substance Abuse Rehab Service Request (PDF)
- Discharge Summary (PDF)
- Electroconvulsive Therapy Services Request (PDF)
- Inpatient, Sub-Acute and CSU Service Request (PDF)
- Medication Reference Guide (PDF)
- PHP and IOP Service Request (PDF)
- Psychological and Neuropsychological Testing Service Request (PDF)
- Residential Treatment Service Request (PDF)
- Routine Outpatient Services Request (PDF)
- Targeted Case Management Service Request (PDF)
Claims
- CMS 1500 Submission Sample (PDF)
- NDC Reporting Guidelines (PDF)
- Process for Corrected Claims or Voided Claims (PDF)
- Refund Check Information Sheet (PDF)
- Refund Referral Grid (PDF)
- Taxonomy Guide (PDF)
- UB-04 Submission Sample (PDF)