First Name, Middle Name, Last Name: First and Last names are required

Suffix, Gender, Date of Birth: Date of Birth is required

DBA (Doing Business As): If you are “doing business as” another name, please include this information in that field. This is only for the provider’s name, not the practice location name. Uploaded IRS documentation is required to verify DBA name. “Doing Business As” is not a required field. DBA name can only be entered if the individual owns 100% of the FEIN. Any value entered in this field will become the DBA name for this provider.

Provider Email Address:  The email address of the provider. The email address must be a match to the email used in KOG (Kentucky Online Gateway) registration. There is a minimum of 5 characters required for an email address. There needs to be (@) included in the address. Web addresses (www) are not allowed in this field. May be the same or different from the Communication Email Address. Confirm this email address by re-entering it in the Confirm Provider Email Address field.

Communication Email Address: The email address where questions about the applications, or notifications should be sent. There is a minimum of 5 characters required for an email address. There needs to be (@) included in the address. Web addresses (www) are not allowed in this field. May be the same or different from the Provider Email Address. Confirm this email address by re-entering it in the Confirm Communication Email Address field.

Requested Effective Date: The requested effective date is pre-populated from the new enrollment page, but can be edited. You are able to request up to a year prior to the current date or 90 days in the future from the current application date.

Application Received Date: The requested effective date is pre-populated from the new enrollment page.

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