Form Map 650 - Epsdt Special Services Home Health Fax Form - Kentucky Cabinet For Health And Family Services Department For Medicaid Services

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Commonwealth of Kentucky
Map -650
Cabinet for Health and Family Services
(Rev 11/08)
Department for Medicaid Services
EPSDT Special Services Home Health Fax Form
Sykes Enterprises and Health Plan Services (SHPS) Phone #: 800-292-2392 ext. 9
Date: ________________________
Reviewing Nurse: _________________________________________ Fax #: ___________________
Reference #: __________________
New Certification: ____________________
Recert: _________________ Change: __________
EPSDT Provider Name: __________________________________________________
Provider #: ___________________________
Patient Name: ________________________________________
Address: __________________________________________________
County Code: _____________
Phone (
)_______________________________
Parent/Guardian: _______________________
Medicaid #: _______________________________________ DOB: ____________________________ Sex: ______________
1. Diagnosis: _____________________ ICD-9: _________________
2. Diagnosis: _________________________
ICD-9 :_____________
Provider Contact Name:___________________________________________Phone:________________________________________________
MD Name: __________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
Phone #: (
) __________-___________________
License #: __________________________________________
Service(s) Requested and Location
Procedure Code
# Units
Start Date
End Date
$ Requested
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