Kentucky Medicaid Vision Forms

If you are interested in participating in this new Medicaid program, you must have, or obtain, a Kentucky Medicaid Provider Identification number.

For your convenience, each form is available in (PDF) format for you to print or download.

National Provider Identifier (NPI) Application:

Providers across all specialty lines are required to have a NPI number. If you have not already done so, click this link to be connected to the National Plan & Provider Enumeration System (NPPES) web site to apply for your NPI number. Get Form

Avesis Eye Medical Provider Application

Ophthalmologists new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form

Kentucky Medicaid Authorization Form

Get Form

Avesis Routine Eye Care Provider Application

Providers new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form

Avesis Eye Medical Provider Agreement

The Provider Agreement outlines the contractual arrangement between "the ophthalmologist" and Avesis. Get Form

Addendum to Provider Agreement

The Addendum to the Eye Medical and Eye Care Provider Agreement has been updated. Get Form

Eye Care Vision Provider Agreement

The Provider Agreement outlines the contractual arrangement between "the optometrist/optician" and Avesis. Get Form

Avesis Routine & Eye Medical Medicaid Provider Manual

The Provider Manual outlines information concerning the Avesis Medicaid Eye Care Program Get Form

Electronic Funds Transfer (EFT)

EFT is available to providers on this panel who are utilizing electronic mediums for eligibility verification and claims submission. Get Form

Send Completed Materials by mail or fax to Provider Services

Mail To:

Avesis Third Party Administrators, Inc.
Attn: Kentucky Network Development
10324 Soulth Dolfield Road
Owings Mills, MD 21117

Phone:
855-469-3368