Map 900 2026

1. Click 'Get Form' to open the map 900 in the editor.
2. Begin with Section A: Administrative Information. Fill in your Kentucky Medicaid provider number and indicate whether you are revalidating as an individual, entity, or group. Ensure that all names match supporting documentation.
3. Provide your Doing Business As (DBA) name if different from your legal name. Enter your email address and select the appropriate boxes for profit/non-profit and public/private status.
4. Complete fields for License/Certification number, Provider Type, Type of Service, National Provider Identifier (NPI), and Taxonomy Code(s). Attach any necessary documents as specified.
5. Proceed to Section B: Disclosure of Ownership and Control Interest. Answer all questions regarding ownership changes, affiliations, and any relevant disclosures accurately.
6. Finally, review all sections to ensure no questions are left blank. Use 'N/A' where applicable. Once completed, save your document and submit it as instructed.

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