Form Map-529 - Kentucky Medicaid Change Of Information Form
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2MAP-529
(REV 5/16)
Kentucky Medicaid Change of Information Form
Current Existing Information
Provider Name: _______________________________________________________________________
For an Individual, list Last Name, First Name, Middle. For an Entity/Group, list complete business name & DBA
Provider Number: __________________________________ NPI: _______________________________________
Contact Name: ________________________________________________________________________
Contact Telephone: ________________________________________________
Email: _______________________________________________________________________________
Contact Information for form preparer, credentialer or provider
Name Change Section
List Only New Information
Name Change to: ______________________________________________________________________
Reason for Name Change: _______________________________________________________________
Required Supporting Documentation:
if applicable
Group/Entity
Individual
__ New IRS Verification
__New CLIA
__New Medicare
__New Social Security Card
__ New Accreditation
__New JCAHO
__New HME
__ New Medical License
__New Facility License
Change of Address Section
List Only New Location Information
Physical
Street: ___________________________________________________________
City: _____________________________________________________________
State: _________ Zip: ______________
Phone: ___________________________ Fax: ___________________________
Correspondence
Street: ___________________________________________________________
City: _____________________________________________________________
State: _________ Zip: ______________
Phone: ___________________________ Fax: ___________________________
Pay-To
Street: ___________________________________________________________
City: _____________________________________________________________
State: _________ Zip: ______________
Phone: ___________________________ Fax: ___________________________
See 1099 box, next page
Return To: Kentucky Medicaid, PO Box 2110, Frankfort, KY 40602-2110, P: 877-838-5085
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