The Kentucky Health Care Provider Application for Certificate of Registration is used by providers of taxable health care items or services to apply for registration with the Kentucky Department of Revenue. Kentucky requires a provider that supplies taxable health care items or services to submit this application to obtain the appropriate certificate of registration. The application collects information that allows the Department of Revenue to identify the health care provider, its legal and business names, service location, mailing address, contact information, federal employer identification number, existing Kentucky tax account numbers, ownership structure, type of health care services provided, professional or facility license numbers, and any current or previous health care provider tax account number. It also requires identifying information for certain owners, partners, and corporate officers, including names, license information, addresses, and Social Security numbers. Partnerships and corporations generally complete one application for the business while identifying the applicable partners and officers in the ownership section. A new application is required when ownership changes. Both sides of the application must be completed, and additional sheets may be attached when more space is needed for owners, partners, officers, or people who hold multiple professional licenses or certifications. An appropriate owner, partner, member, or executive officer must sign the completed application before it is submitted.
How To File The Kentucky Health Care Provider Application
Complete every applicable section of the application, including the information requested on the reverse side. Do not stop after completing only the business information on the first side.
If there is not enough space to identify all owners, partners, officers, professional licenses, or certifications, use additional sheets to provide the remaining information.
An authorized owner, partner, member, or executive officer must sign the application. Review all identifying numbers, addresses, license information, and tax account numbers before signing.
Mail the completed application to:
Kentucky Department of Revenue
Station 62
Frankfort, Kentucky 40620
For additional information about the application, the Department of Revenue contact number shown on the form is (502) 564-6823.
How To Complete The Kentucky Health Care Provider Application Line By Line
Header Information
The top portion identifies the application and provides areas for mailing and administrative use.
Name And Address
The upper-left box is designated for the applicant’s name and address information.
Enter or provide the applicant’s identifying name and address in this area when appropriate.
Kentucky Health Care Provider Application For Certificate Of Registration
This heading identifies the purpose of the application. It is specifically used to apply for registration as a Kentucky health care provider for applicable tax purposes.
For Official Use Only
Do not complete this box.
It is reserved for use by the Kentucky Department of Revenue when processing the application.
General Information
This section explains who must apply and when a new application may be necessary.
Providers Of Taxable Health Care Items Or Services
A provider of health care items or services that are taxable in Kentucky must apply for a certificate of registration with the Department of Revenue.
Complete the application when your health care operation falls within the taxable provider requirements described by the application.
Partnerships And Corporations
A partnership or corporation should submit a single application for the business.
The applicable partners or corporate officers must then be identified in the section provided on the reverse side.
Changes In Ownership
Submit a new application when there is a change in ownership.
Do not assume an existing registration application continues to cover a newly changed ownership structure.
Additional Information
Questions about the registration process may be directed to the Kentucky Department of Revenue in Frankfort at (502) 564-6823.
Application Completion Requirements
The instructions require all sections to be completed.
If the available lines are insufficient for owners, partners, officers, or people with multiple professional licenses or certifications, attach additional sheets with the necessary information.
The completed application must be signed by an appropriate owner, partner, member, or executive officer.
The reverse side must also be completed before the application is filed.
Name Of Applicant
This section identifies the health care provider applying for registration.
Legal Name
Enter the applicant’s complete legal business name.
Use the name under which the individual, partnership, corporation, or other organization is legally established.
DBA
Enter the applicant’s “doing business as” name if the business operates under a name different from its legal name.
If the legal name and operating name are different, make sure the DBA entry identifies the name commonly used by the business.
Beginning Date Of Operation
Enter the date on which the business began operating.
Use the beginning date that applies to the health care provider operation covered by this application.
Service Location
This section asks for the physical location where the health care provider conducts its operations.
Number And Street
Enter the street number and street name for the service location.
Use the physical business location associated with the health care services covered by the registration.
City
Enter the city where the service location is situated.
County
Enter the Kentucky county in which the service location is located.
State
Enter the state for the service location.
ZIP Code
Enter the ZIP Code associated with the service address.
Review the full service location before continuing so the street, city, county, state, and ZIP Code all refer to the same location.
Mailing Address
Use this section for the address where the provider receives correspondence.
P.O. Box Or Number And Street
Enter either the applicable post office box or the street number and street name for the mailing address.
The mailing address may be different from the physical service location.
City
Enter the city associated with the mailing address.
State
Enter the state for the mailing address.
ZIP Code
Enter the ZIP Code for the mailing address.
Business Information
This section collects contact information, the federal employer identification number, and existing Kentucky account numbers.
Telephone Number
Enter the business telephone number, including the area code.
Use a number where the provider or an appropriate business representative can be contacted.
FAX Number
Enter the business fax number, including the area code, if applicable.
Federal Employer I.D. Number
Enter the applicant’s Federal Employer Identification Number.
Carefully check each digit before submitting the application.
Kentucky Employer’s Withholding Account Number
If the applicant has a Kentucky Employer’s Withholding account number, enter it on the corresponding line under Account Number.
Use the account number specifically associated with Kentucky employer withholding.
Kentucky Corporation Income And License Account Number
Enter the applicable Kentucky Corporation Income and License account number if the applicant has one.
Make sure this number is entered on its designated line rather than under another tax account category.
Kentucky Sales And Use Account Number
Enter the provider’s Kentucky Sales and Use account number when applicable.
Kentucky Unemployment Insurance Account Number
Enter the Kentucky Unemployment Insurance account number associated with the business when applicable.
Type Of Ownership
Select the option that correctly describes how the applicant is legally owned.
Individual
Check Individual when the applicant operates under an individual ownership structure.
Partnership
Check Partnership when the applicant is organized as a partnership.
Partners must also be identified in the ownership information requested on the reverse side.
Corporation
Check Corporation when the applicant operates as a corporation.
Applicable corporate officers must be identified on the reverse side.
Other
Check Other when none of the listed ownership categories accurately describes the organization.
Use the space provided to describe the ownership structure.
Type Of Health Care Services
Select the health care service category or categories that apply to the applicant and provide the requested license number.
Hospital Services
Check this box if the applicant provides hospital services.
Enter the applicable license number on the line beside this category.
Nursing Facilities Services
Select this category when the applicant provides nursing facility services.
Enter the corresponding license number.
Services Of An ICF/MR
Check this option when the provider supplies services falling within the ICF/MR category.
Enter the applicable license number in the space provided.
Home Health Care Agency Services
Select this category if the applicant provides home health care agency services.
Enter the agency’s applicable license number.
Supports For Community Living
Check this box when the applicant provides Supports for Community Living services.
Provide the corresponding license number.
Other
Select Other when the applicant’s applicable health care service does not fit one of the listed categories.
Describe the service in the space provided and enter the applicable license number.
Current Or Previous Health Care Provider Tax Account Number
Enter any current or previous Health Care Provider Tax Account Number associated with the applicant.
This field allows the provider to identify an existing or earlier account connected with health care provider tax reporting.
Owner, Partner, And Officer Information
The reverse-side section collects information about individuals connected with the ownership or management of the applicant.
Complete the appropriate title selection and identifying fields for each person who must be reported.
The columns request the person’s name, license number, city, state, and ZIP Code. A separate line also requests the person’s home address and Social Security number.
Title Selection
Check the title that applies to each person being reported.
President
Check President when the individual serves as president of the organization.
Then complete the identifying information requested across that person’s row.
Partner
Check Partner when the person is a partner in the business.
The partner option appears alongside the officer categories so the appropriate relationship can be identified.
Individual
Check Individual when this designation applies to the person being reported.
Complete the remaining identifying information for that individual.
Vice President
Check Vice President for the individual who holds that corporate position.
Complete the person’s name, licensing information, location information, home address, and Social Security number.
Secretary
Check Secretary for the person serving in that corporate office.
Provide the requested information on the corresponding lines.
Treasurer
Check Treasurer for the individual serving as treasurer.
Complete all identifying fields associated with that entry.
Name
Enter the full name of the person associated with the checked title.
Use one person’s information for each applicable entry.
License Number
Enter the professional or other applicable license number associated with that person.
If an individual has multiple professional licenses or certifications and the available space is insufficient, provide the additional information on an attached sheet.
City
Enter the city associated with the person’s requested address information.
State
Enter the appropriate state.
ZIP
Enter the ZIP Code associated with the person’s address.
Home Address
Enter the home address of the individual listed in that entry.
Make sure the home address belongs to the same person whose title and name appear in the corresponding section.
SSN
Enter the person’s Social Security number in the spaces provided.
Check the digits carefully before filing the application.
Signature And Contact Information
This section is used to certify the completed application and identify the person signing it.
Signature
The appropriate owner, partner, member, or executive officer should sign the application on this line.
Do not submit an unsigned application when a signature is required.
Title
Enter the signer’s position or title.
For example, the title should identify the capacity in which that person is authorized to sign for the applicant.
Date
Enter the date the application is signed.
Enter the email address associated with the signer or appropriate business contact.
Use an email address through which the provider can receive communications.
Telephone Number
Enter the telephone number for the signer or appropriate contact person, including the area code.
Other Information
Use the Other Information area to provide additional details that are necessary for the application but do not fit into the earlier fields.
The section contains several blank lines so the applicant can explain or supplement information when necessary.
Additional information may also be useful when the applicant needs to clarify an ownership, licensing, registration, or business detail already entered elsewhere on the application.
If more space is required for owners, partners, officers, or multiple professional licenses or certifications, use additional sheets as directed rather than attempting to squeeze extensive information into the available lines.
Final Review Before Filing
Before mailing the application, make sure the legal name, DBA, beginning date of operation, service location, mailing address, telephone number, fax number, Federal Employer Identification Number, and applicable Kentucky account numbers have been completed. Confirm that the correct ownership type has been selected and that each applicable health care service category includes its license number.
Next, check any current or previous Health Care Provider Tax Account Number and complete the required information for owners, partners, and officers on the reverse side. Review each person’s title, name, license number, city, state, ZIP Code, home address, and Social Security number for accuracy.
Finally, make sure both sides have been completed, attach additional sheets when necessary, provide any relevant information in the Other Information section, and have an authorized owner, partner, member, or executive officer sign and date the application before mailing it to the Kentucky Department of Revenue.