Business Name: Business name 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.

Group/Entity Owner Email Address: The email address of the business. 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.

Business Ownership Type: Select the Business Ownership Type from the dropdown box

• Private Ownership- Company is owned by private shareholders

• Public Ownership- Company issues shares for subscription by the public.  Can be government owned

Business Structure Type: Select the Business Structure Type from the dropdown box

• Profit

• Non Profit

Fiscal Year End: Select the Fiscal Year End from the dropdown box

Requested Effective Date: The requested effective date is prepopulated 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.

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