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Forms

Access key forms for authorizations, claims, pharmacy and more.

Kentucky HEALTH

This Attestation is to be completed by an enrolled Medicaid Provider whose scope of expertise qualifies them to assess the Member for "medical frailty".

This Guide is a reference to Medicaid Providers and Clinicians as they complete the “Kentucky Medically Frail Provider Attestation” form for determination of possible medically frail members.

Administrative

The EPSDT Well Child Exam form is intended for providers to utilize when performing a complete well child exam.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Well Child Exam

Use this form to request a PCP change for a member.

Appeals and Grievances

Complete this form to submit an appeal.

Complete this form to submit a grievance.

Authorizations

Complete and submit this form online in order to request a prior authorization.

Print, complete and then mail this form in order to request a prior authorization.

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Pharmacy

Kentucky Medicaid Substance Use Treatment Pharmacy Prior Authorization Form For Buprenorphine Products

Please fax completed form to the corresponding fax number of the health plan partner your patient is currently enrolled.

Instructions: Please complete all fields and fax completed form to 1-855-620-1868

Form must be completed, signed and submitted by a physician with a Drug Addiction Treatment Act (DATA) waiver (UIN #).


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Last Updated On: 5/17/2018