In an age where efficiency and security in financial transactions are paramount, the MAP-811 Addendum E form emerges as a significant tool for providers engaged with the Department for Medicaid Services. This form facilitates a smooth transition for providers to either enroll in or change their direct deposit information, ensuring that payments for Medicaid services are deposited directly into their specified bank accounts. With options to select between checking and savings accounts, it simplifies the process, making it not just user-friendly but also adaptable to the provider's preference. The importance of keeping bank details up-to-date is underscored by the commitment to notify the Kentucky Medicaid agency immediately should any changes occur, safeguarding against misplaced payments. Also, it offers a mechanism for canceling the direct deposit authorization, should a provider choose to revert to alternative payment methods. The inclusion of detailed instructions for each field in the form makes it accessible, aiming to mitigate errors and encourage accurate submissions. By signing the form, providers not only authorize the Department for Medicaid Services to initiate these transactions but also acknowledge the legal implications of such financial activities, which derive from federal and state funds. This form stands as a testament to the ongoing efforts to enhance the administrative aspects of healthcare services, ensuring that providers can focus more on delivering care and less on navigating bureaucratic complexities.
| Question | Answer |
|---|---|
| Form Name | Map 811 Addendum E Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | map 811 addendum e, ky medicaid map 811 addendum e, 811 addendum e, map 811 direct deposit form |
DEPARTMENT FOR MEDICAID SERVICES
DIRECT DEPOSIT AUTHORIZATION/CANCELLATION FORM
Complete the following provider information:
Provider Name: ___________________________________
Provider Number: ___________________NPI (National Provider Identifier) ____________________
Address: _________________________________________________________
City: __________________________State: ______________ Zip: ___________
Telephone Number: ______________________Contact Name _______________________________
New Enrollment
Institution or Account Change
Bank Name ______________________________________________________
Branch or correspondent Bank (if applicable) ____________________________
City _________________________ State: ________________ Zip:__________
Transit/ABA Number: _______________________Account Number: ________________________
Account Type (select one):
Checking
Savings
I, the undersigned, authorize the Department for Medicaid Services to initiate accounting transactions to deposit payments directly to the account indicated above. These deposits will pertain only to direct deposit payments for Medicaid services that the payee has rendered.
I understand that in the event that my account information should change, I must notify the Kentucky Medicaid agency immediately. I will not hold the Kentucky Medicaid agency liable for presentation of any or all direct deposits into the account indicated above if I fail to notify Kentucky Medicaid or the fiscal agent of my change in bank account information.
I understand in endorsing or depositing this check (EFT) that payment will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.
Signature _________________________________________________Date: _________________
Title ___________________________________________________________________________
Cancellation
I, the undersigned, hereby cancel the authorization for the Department for Medicaid Services to originate direct deposit entries into my checking/savings account. This cancellation is effective on date of receipt.
Signature: ________________________________________________Date: _________________
Title: ___________________________________________________________________________
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INSTRUCTIONS FOR DIRECT DEPOSIT AUTHORIZATION/CANCELLATION FORM
FIELD NAME |
FIELD INSTRUCTION |
Provider Name |
Enter the personal or business name. |
Provider Number |
Enter the KY Medicaid provider number assigned to the provider for services |
|
rendered to KY Medicaid members. |
NPI |
|
(National Provider Identifier) |
Enter the provider’s NPI. |
Address |
Enter the physical address. |
City |
Enter the physical city. |
State |
Enter the physical state. |
Zip |
Enter the physical zip code. |
Telephone Number |
Enter the telephone number where the provider can be reached during |
|
normal business hours. |
Contact Name |
Enter the name of the individual that can be contacted at the number |
|
indicated above. |
New Enrollment/Institution |
Indicate by marking the appropriate block if this form is for a new |
or Account Change |
enrollment or a change to previous information. |
Bank Name |
Enter the name of the provider’s financial institution. |
Branch or Correspondent |
Enter branch name or major bank or the provider’s financial |
Bank |
institution if applicable. |
City, State, Zip |
Enter physical city, state, and zip where the financial institution indicated |
|
above is located. |
Transit/ABA Number |
Enter the nine digit American Banking Association (ABA) identifying |
|
number for the financial institution indicated above. This number can be |
|
obtained from the institution or is normally the first nine digits of the |
|
electronic coding at the bottom of the check or deposit slip. |
Account Number |
Enter the provider’s account number at the financial institution indicated |
|
above. |
Account Type |
Indicate by marking the appropriate block whether you would like the funds |
|
be deposited into checking or savings account. |
Signature |
Signature of provider or authorized representative of the provider. |
Date |
Date this form is signed. |
Title |
Title of the individual signing this form. |
Cancellation Block |
If you wish to cancel the direct deposit, please mark the cancellation box and |
|
sign and date form. |
Signature |
Signature of provider or authorized representative of the provider. |
Date |
Date this form is signed. |
Title |
Title of the individual signing this form. |
|
SUBMIT COMPLETED FORM TO: |
|
KY Medicaid |
|
P.O. Box 2110 |
|
Frankfort, KY |
|
Telephone: |
|
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