Map 900 2025

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4.8 out of 5

141 votes

The Map-900 Checklist provides detailed instructions for enrolling or revalidating as a Kentucky Medicaid provider. It outlines necessary documentation, including completion of application questions, required signatures, and attachments such as licenses, certifications, and verification documents. The document emphasizes the importance of accuracy and completeness to avoid application delays and includes sections on administrative information, ownership disclosure, attestations regarding licensure and criminal history, and compliance with Medicaid rules. Providers are instructed to submit their applications to the specified address and retain copies for their records.

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Click 'Get Form' to open the map 900 in the editor.
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.
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.
Complete fields for License/Certification number, Provider Type, Type of Service, National Provider Identifier (NPI), and Taxonomy Code(s). Attach any necessary documents directly within the editor.
Proceed to Section B: Disclosure of Ownership and Control Interest. Answer all questions regarding ownership changes, affiliations, and any relevant disclosures accurately.
Finally, review all sections for completeness. Remember to sign and date the signature page electronically before submitting your application through our platform.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (141 Votes)
2015	4.4 Satisfied (260 Votes)
2014	4.3 Satisfied (167 Votes)

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