Frequently Used Forms
Provider Contracting and Credentialing
- Disclosure of Ownership and Control Form
- Practitioner Application Form
- Provider Contract Request Form
- Provider Information Update Form
- Healthcare Delivery Organization Form/Blank Attestation Form
- Group Roster Template
Prior Authorizations
- Behavioral Health Prior Authorization Form
- SUD Review Form
- Prior Authorization Code Matrix - Q2 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
Appeals & Grievances
Other Resources
- PCP Member Dismissal Form
- PRAPARE - Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
- Pregnancy Notification Report
- Request to Change Primary Care Provider
- Health Education and Care Management Referral Form
- KY Medicaid Commercial Bypass List
- KY Medicaid Commercial Insurance Coverage Provider Attestation Form
- KY Medicaid Commercial Bypass Codes
- KY Provider Early Reversal Permission Form