Map-572a - Auto Transportation Provider Agreement
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1MAP-572A (Rev. 02/16)
Final approval by OTD management:
To be completed by KY Medicaid:
Reviewed by:_______________
COMMONWEALTH OF KENTUCKY
Provider Number:
Date:______________________
Cabinet For Health and Family Services
56_____________________
Department For Medicaid Services
To be completed by OTD:
Div. of Program Integrity checks
Verified Information:
Private Auto
completed by:
(for Private Auto Providers only)
Transportation
Signature:________________
Provider Agreement
Signature:__________________
Date:____________________
Date:______________________
Each individual applying for a Kentucky Medicaid transportation provider number must complete a separate form.
_______________________________________________
_________________________________________
(Print your full name)
(Social Security Number)
The applicant agrees to:
Transport Medicaid recipients to and/or from medical services and provide referrals for outside the medical service area;
Obey all applicable federal and state laws and regulations concerning the Kentucky Medicaid Program and the Kentucky
Transportation Cabinet (driver’s license, automobile/vehicle registration and insurance requirements);
Not discriminate on the basis in the provision of services due to age, handicap, national origin, race, or sex in the prevision of
service;
Keep all records of all transportation services provided to Medicaid recipients for a minimum of five (5) years (letters,
statements, etc.) for review purposes;
Notify the Cabinet For Family and Health Services, Department For Medicaid Services of any name or address change.
I understand there may be civil or criminal penalties if I intentionally defraud the Department For Medicaid Services.
The provider or the Cabinet may terminate this agreement at any time. This constitutes the entire agreement between the Cabinet for
Family and Health Services and the provider.
APPLICANT INFORMATION:
(FOR AGENCY USE ONLY)
Department For Medicaid Services
Original Signature:________________________________
Authorized Signature:___________________________
Date:___________________________________________
Title:________________________________________
Physical Address:_________________________________
Approval Date:________________________________
_______________________________________________
Mailing Address:_________________________________
(FOR BROKER USE ONLY)
_______________________________________________
Broker Name:_________________________________
Email Address: ___________________________________
Broker Signature:______________________________
Driver’s License Number:___________________________
Residing County:__________________________________
Approval Date:________________________________
Phone Number:__(________) _______________________
CLEAR FORM
Please return form to:
KY Medicaid Provider Enrollment, P.O. Box 2110, Frankfort, KY 40602-2110
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