Facility or Ancillary Provider EnrollmentAll fields with an asterisk (*) MUST be completed Contact InformationBy default, all correspondence regarding this application will be communicated using the information provided in this section. Contact Info*NamePhoneEmail* Facility InformationFacility Name Legal Name DBA (if applicable) Date Facility Opened MM slash DD slash YYYY Physical Location Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone/FaxPhoneFax Are EPSDT services provided at this site?* Yes No Are American Sign Language services provided at this site?* Yes No Are Telemedicine services provided at this site?* Yes No Does this site participate in KHIE?* Yes No Practice Website* Website may be published in payer directoryPractice Email* Email may be published in payer directoryPay-To Address same as Physical Location Address Yes No Pay-to Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pay-To Phone/FaxPhoneFax Correspondence Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Correspondence Phone/Fax/E-mailPhoneFaxE-mail Federal Tax ID # National Provider Identifier (NPI) State License #DEA # (If Applicable)Is Facility Compliant with ADA (Americans with Disabilities Act)?* Yes No Type of Facility Hospital (Acute & Rehabilitation) Mental Health & Substance Abuse Services Home Health Agency Skilled Nursing Facility / Nursing Home Free-standing Surgical Center Other Demographic InformationCEO/Administrator NameBusiness Manager NameMedicaid ParticipationDo you wish to participate with KY Managed Medicaid plans via Center Care? Yes No Do you have a Kentucky Medicaid #? Yes No Kentucky Medicaid # Medicare Advantage ParticipationDo you wish to participate with Managed Medicare Advantage plans via Center Care? Yes No Do you have a Medicare #? Yes No Medicare # Current AccreditationsAccreditation Information TJC AOA CARF CHAP AAAASF AAAHC CMS HFAP Unaccredited (site visit must be performed) Please attach a letter/certificate of accreditation upon submitting this form.Laboratory ServicesDoes this facility offer lab services? Yes No CLIA Certificate/Waiver #: Liability InsuranceLiability Insurance InformationCarrier NameExpiration DateLimitsPlease attach a certificate of insurance (COI) upon submitting this form.Sanctions, Disciplinary Actions, Legal RestraintsPlease attach explanation of any affirmative responses upon submitting this form.Has this facility been subject to any revocations, suspensions, or sanctions under Medicare/Medicaid? Yes No Has this facility's professional or general liability insurance ever been denied/cancelled? Yes No Has this facility's license ever been suspended, revoked, investigated, or disciplined? Yes No Does this facility have any pending malpractice claims? Yes No Total number of pending malpractice claims NotesNotes/CommentsPlease provide any comments that may assist in processing your request.Required DocumentationPlease indicate below that you have attached the following necessary required documents. Attach the supporting documentation to this submission in the field provided below. Failure to submit the necessary documentation may result in the provider's application being deemed incomplete, requiring resubmission of the application. This may also result in a delay of the provider's effective date for participation. Attachments Copy of state license DEA Certificate Copy of certificate of liability insurance (COI) Copy of accreditation letter/certificate OR CMS certification status/site assessment report (if non-accredited) Explanation for sanctions, disciplinary actions, legal restraints (if any) Ownership Disclosure Form Sample Claim Form W-9 Form Upload FilesPlease upload the required documentation here, as applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 8. Attestation*By choosing "Yes, I agree" below, you hereby certify that the information provided is accurate and complete, and you understand that falsification of this information is grounds for loss of participation with Center Care. You further agree to provide information, as may be requested by Center Care, to support this application. Yes, I agree.
