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Medicaid Map 900 - Fill Out and Sign Printable PDF …
WebMust be a provider for Kentucky Medicaid Program, or must complete the provider enrollment application immediately upon hire or achievement of independent licensure. Must be willing to complete the Kentucky Medicaid Program Statement of authorization for Payment form, (MAP 347) to allow CHNK to bill for services through your Medicaid … Web1. Medicaid I.D. No. 2. Recipient Last Name: 3. First Name: 4. M.I. Ten Digits 5a: Provider Number 6a. Provider Name, Address, and Phone Number 7. Co. # of Recipient … hand holding the moon
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