Access key forms for authorizations, claims, pharmacy and more.
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.
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.
Complete this form to submit an appeal.
Complete this form to submit a grievance.
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.
Refund Check Information Sheet* (RCIS)
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 #).