Form Map 529 PDF Details

Navigating the updates and changes in one's professional details can often seem like a daunting task, especially for those in the healthcare sector tangled in the web of Medicaid services. The MAP-529 form, a critical document for Kentucky Medicaid providers, emerges as a beacon of order, guiding providers through the necessary steps to update vital information. This form, with its comprehensive structure, targets various segments of a provider's portfolio—ranging from simple name changes and address updates to more complex alterations like the termination of a Kentucky Medicaid number. It meticulously outlines the details required for individual and entity/group providers, specifying the kind of documentation necessary for each update. Whether it's a shift in location, a change in contact details, or a significant transition like the termination of services, the MAP-529 form stands as a testament to Kentucky Medicaid's dedication to maintaining current and accurate provider information. It not only facilitates a smoother communication channel between Medicaid and its providers but also ensures that the data on file accurately reflects the current status of those providing care under its aegis. Essential for compliance and operational accuracy, this form embodies the procedural integrity required in the ever-evolving healthcare landscape.

QuestionAnswer
Form NameForm Map 529
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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Form Preview Example

MAP-529 (REV 5/16)

Kentucky Medicaid Change of Information Form

Current Existing Information

Provider Name: _______________________________________________________________________

For an Individual, list Last Name, First Name, Middle. For an Entity/Group, list complete business name & DBA

Provider Number: __________________________________ NPI: _______________________________________

Contact Name: ________________________________________________________________________

Contact Telephone: ________________________________________________

Email: _______________________________________________________________________________

Contact Information for form preparer, credentialer or provider

Name Change Section

List Only New Information

Name Change to: ______________________________________________________________________

Reason for Name Change: _______________________________________________________________

Required Supporting Documentation:

if applicable

 

Group/Entity

 

 

Individual

__ New IRS Verification

__New CLIA

__New Medicare

__New Social Security Card

__ New Accreditation

__New JCAHO

__New HME

__ New Medical License

__New Facility License

 

 

 

Change of Address Section

List Only New Location Information

Physical

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________

Zip: ______________

 

Phone: ___________________________ Fax: ___________________________

 

 

Correspondence

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________

Zip: ______________

 

Phone: ___________________________ Fax: ___________________________

 

 

Pay-To

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________

Zip: ______________

 

Phone: ___________________________ Fax: ___________________________

See 1099 box, next page

Return To: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602-2110, P: 877-838-5085

MAP-529 (REV 5/16)

1099

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________ Zip: ______________

Phone: ___________________________ Fax: ___________________________

Additional Location Section

List Only New Location Information

Physical Address

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________

Zip: ______________

 

Phone: ___________________________ Fax: ________________________

 

 

Physical Address

Street: ___________________________________________________________

 

City: _____________________________________________________________

 

State: _________

Zip: ______________

Phone: ___________________________ Fax: ________________________

Change to Contact Information

List Only New Information

Contact Name:_______________________________________________________________________

Contact Telephone:________________________________________________

Email: _______________________________________________________________________________

Contact Information for form preparer, credentialer or provider

Request To Terminate Kentucky Medicaid Number

I, _________________________________________, request to terminate my contract with

Name

Kentucky Medicaid, effective ___________________________.

End Date

Medicaid Number that I am terminating: ______________________________________

I authorize Kentucky Medicaid to change the current information on file to the information indicated on this form. For an individual, the individual provider’s signature is required.

Printed Name: _____________________________________________ Title: ______________________

Provider Signature: _________________________________________ Date: ______________________

Return To: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602-2110, P: 877-838-5085

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Filling out this form needs focus on details. Make certain every blank field is completed accurately.

1. It is critical to complete the kentucky chfs 529 information accurately, so pay close attention while working with the segments that contain all these blanks:

The best way to fill out kentucky information form printable stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - New Accreditation, New JCAHO New HME, New Medical License, New Facility License, Change of Address Section, List Only New Location Information, Physical, Street, City, State Zip, Phone Fax, Correspondence, Street, City, and State Zip with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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You can easily make errors when filling out the City, hence be sure you take another look before you decide to send it in.

3. In this specific part, check out Street, City, State Zip, Phone Fax, Additional Location Section, List Only New Location Information, Physical Address, Street, City, State Zip, Phone Fax, Physical Address, Street, City, and State Zip. Each of these have to be filled out with greatest precision.

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4. To move onward, this form section requires typing in several fields. Examples include Contact Name, Contact Telephone, Email, Contact Information for form, Request To Terminate Kentucky, I request to terminate my, Name, Kentucky Medicaid effective, End Date, Medicaid Number that I am, I authorize Kentucky Medicaid to, on this form For an individual the, and Printed Name Title, which you'll find integral to moving forward with this particular PDF.

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