Frequently Used Forms
Provider Contracting and Credentialing
- Disclosure of Ownership and Control Form
- Facility/HealthCare Delivery Organization (HDO)/Long Term Special Services (LTSS) Credentialing Application
- Healthcare Delivery Organization Form/Blank Attestation Form
- Group Roster Template
- Healthcare Delivery Organization Form/Blank Attestation Form
- Provider Contract Request Form
- Provider Information Update Form
- Request to Add New Provider Form
Prior Authorizations
- Cosmetic
- DME
- Home Health
- Inpatient
- KY Medicaid Pharmacy Prior Authorization Form
- KY Universal Prior Authorization Request Form
- Long-Term Care Fax Form
- Oncology Services Matrix
- Passport Evolent KY Provider Matrix
- Prior Authorization Code Matrix - Q4 2023
- Prior Authorization Code Matrix - Q1 2024
- Prior Authorization Code Matrix - Q2 2024
- Prior Authorization Code Matrix - Q3 2024
- Prior Authorization Code Matrix - Q4 2024
- Prior Authorization Code Matrix - Q1 2025
- Prior Authorization Code Matrix - Q2 2025
- Prior Authorization Code Matrix - Q3 2025
- Prior Authorization Guide
- Prior Authorization LookUp Tool
- SUD Review Form
- Therapy
Appeals & Grievances
- Appointment of Representative Form
- Provider Appeal Form
- Provider External Independent Third-Party Review Form
- Provider Grievances Form
Behavioral Health Authorization Forms
- ABA Authorization Request Form
- Comprehensive Community Supports Authorization Request Form
- Concurrent Authorization Request Form
- Day Treatment Authorization Request Form
- H0038 H2027 Authorization Request Form
- Initial Inpatient Authorization Request Form
- TCM Authorization Request Form
Other Resources
- Consent for Sterilization
- Healthy Rewards Information and Attestation Form
- Health Education and Care Management Referral Form
- Hysterectomy Consent Form
- KY DMS Notification of Pregnancy
- KY Medicaid Commercial Bypass Codes
- KY Medicaid Commercial Bypass List
- KY Medicaid Commercial Insurance Coverage Provider Attestation Form
- KY Provider Early Reversal Permission Form
- Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial
- Medicaid Clinical Trial Attestation Form
- PCP Member Dismissal Form
- PRAPARE - Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
- Request to Change Primary Care Provider