List the names and addresses of all other Kentucky Medicaid providers with which your health service and/or facility engages in a significant business transaction and/or a series of transactions that during any one (1) fiscal year exceed the lesser of $25,000 or 5% of your total operating expense.

Significant Business Transaction – indicates any business transaction or series of transactions that, during any one fiscal year, exceeds the lesser of $25,000 or 5% of applicant’s operating expense.

Subcontractor – indicates an individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients, OR an individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or lease of real property) to obtain space, supplies, equipment or services provided under the Medicaid agreement.

Name

• Enter the First and Last Name.  Initials are not accepted in this field

OR

Provider Business Name

• Enter the Provider Business Name

Address

• Enter the address information in this field

City

• Enter the appropriate city for the applicable address

State

• State defaults to Kentucky but is editable

• Select the appropriate state from the drop down box

Zip Code

• Enter the appropriate zip code for the applicable address entered

Zip+4

• If known, enter the appropriate +4 Zip code

For applicants enrolling under Individual Category, the system shall default value to N/A and the user will not be able to modify any fields on this screen.  They may click “Exit,” “Back,” or “Save & Next”

If fields are entered then N/A is checked, the data entered will be cleared

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page