The Kentucky Ground Ambulance Provider Monthly Return (Form 73A065) is a mandatory tax document issued by the Commonwealth of Kentucky’s Department of Revenue. This form is specifically designed for Kentucky Ambulance Emergency Medical Services to report and pay the Ground Ambulance Provider Assessment Tax. The assessment funds healthcare initiatives and is calculated based on monthly net emergency services collections. Every licensed ground ambulance provider must file this return on a monthly basis to declare their collections and calculate the tax due using a fixed rate of 5.5%. The data required to complete this form comes directly from the “Ambulance Provider Assessment Program Survey” provided by the Cabinet for Health and Family Services. Filing this return accurately ensures compliance with state regulations and proper contribution to the state’s healthcare funding systems.
How To File It?
You must file Form 73A065 every month. The deadline is the 20th day of the month following the reporting period. For example, the return for January is due by February 20th. If the 20th falls on a weekend or holiday, the due date shifts to the next business day.
There are two primary ways to submit your payment and return:
- By Mail: Make your check payable to “Kentucky State Treasurer” and mail it along with the completed form to the Kentucky Department of Revenue, Frankfort, KY 40619.
- Online: You can make payments electronically via the official state payment portal at https://epayment.ky.gov/EPAY.
How To Complete It? (Line-By-Line Instructions)
Follow these detailed, step-by-step instructions to ensure your return is error-free.
Header Section: Provider Information
- Name And Address: Enter the full legal business name and mailing address of your ground ambulance service.
- Account Number: Input your Kentucky tax account number, which is the same as your Medicaid ID number.
- Report For The Month: Clearly state the specific month and year for which you are filing the return (e.g., “January 2025”). Do not confuse this with the month you are filling out the form.
Assessment Fee Calculation (Lines 1-3)
- Line 1 (Monthly Net Emergency Services Collections): Enter the amount of your “Monthly Net Emergency Services Collections.” You must obtain this figure from your “Ambulance Provider Assessment Program Survey” for the current calendar year (CY) under the “Provider Tax Assessment Reporting” section. Do not estimate this number; use the specific data provided by the survey.
- Line 2 (Tax Rate): This line is pre-filled or fixed at 5.5%.
- Line 3 (Assessment Amount): Multiply the amount on Line 1 by the 5.5% tax rate (Line 2). Enter the result here. This figure represents the total tax you owe for the month and should match the “Monthly Ground Ambulance Provider Assessment Amount” listed on your survey.
Certification And Signature
- Signature: A principal officer of the ambulance service must sign the form to certify that the information is true and correct to the best of their knowledge.
- Details: Print the signer’s Title, E-mail address, and Telephone Number.
- Date: Enter the date the form was signed.
Additional Assistance
- If you have questions regarding the survey data needed for Line 1, contact the designated survey representatives (e.g., Bradford Johnson or Adam Patton at the email addresses listed in the instructions).
- For general tax questions, you can contact the Department of Revenue at (502) 564-6823 or visit revenue.ky.gov.