Kentucky Medicaid Dental 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) formatpdf 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

Dental 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

Dental Care Provider Agreement

The Provider Agreement outlines the contractual arrangement between "the provider" and Avesis. 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