Frequently Used Forms
Provider Contracting and Credentialing
- Disclosure of Ownership and Control Form
- Provider Contract Request Form
- Provider Information Update Form
- Healthcare Delivery Organization Form/Blank Attestation Form
- Group Roster Template
- Facility/HealthCare Delivery Organization (HDO)/Long Term Special Services (LTSS) Credentialing Application
- Request to Add New Provider Form
Prior Authorizations
- Behavioral Health Prior Authorization Form
- SUD Review Form
- Prior Authorization Code Matrix - Q2 2024
- Prior Authorization Code Matrix - Q1 2024
- Prior Authorization Code Matrix - Q4 2023
- Prior Authorization Guide
- Prior Authorization LookUp Tool
- Cosmetic
- DME
- Home Health
- Inpatient
- Therapy
- KY Universal Prior Authorization Request Form
- KY Medicaid Pharmacy Prior Authorization Form
- Long-Term Care Fax Form
- Oncology Services Matrix
Appeals & Grievances
- Provider Appeal Form
- Provider Grievances Form
- Provider External Independent Third-Party Review Form
- Appointment of Representative Form
Other Resources
- PCP Member Dismissal Form
- PRAPARE - Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
- Pregnancy Notification Report
- Medicaid Clinical Trial Attestation Form
- Request to Change Primary Care Provider
- Health Education and Care Management Referral Form
- Healthy Rewards Information and Attestation Form
- Hysterectomy Consent Form
- KY Medicaid Commercial Bypass List
- KY Medicaid Commercial Insurance Coverage Provider Attestation Form
- KY Medicaid Commercial Bypass Codes
- Consent for Sterilization
- KY Provider Early Reversal Permission Form
- Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial