The Kentucky Health Care Provider Application for Certificate of Registration (Form 73A061) is an official state document mandated by Kentucky law for any entity or individual providing taxable healthcare items or services within the Commonwealth. Its primary purpose is to register these providers with the Kentucky Department of Revenue, ensuring they are legally recognized to conduct business and are set up to pay the necessary provider taxes. This single application covers various business structures, including partnerships and corporations, though a new application must be submitted whenever there is a change in ownership. By filing this form, healthcare businesses—ranging from hospitals and nursing facilities to home health agencies—formally establish their tax accounts with the state, a critical step for regulatory compliance and lawful operation.
How To File It?
Filing the 73A061 application involves completing the physical form and mailing it to the correct state office. Once you have filled out all sections, including the reverse side, the document must be signed by an owner, partner, member, or executive officer to be valid. The completed application should be mailed directly to the Department of Revenue, Station 62, Frankfort, Kentucky 40620. If you need additional space for listing partners or officers, you are permitted to attach extra sheets to your submission.
How To Complete It? (Line-By-Line Instructions)
Follow these specific instructions to complete every section of the application accurately.
Section 1: Applicant Information
- Legal Name: Enter the full legal name of the business entity or individual applicant.
- DBA (Doing Business As): If you operate under a trade name different from your legal name, write it here.
- Beginning Date Of Operation: Specify the exact date your business started providing services.
Section 2: Service Location
- Physical Address: Provide the street number, street name, city, county, state, and ZIP code where your healthcare services are physically performed.
Section 3: Mailing Address
- Contact Address: Enter the P.O. Box or street address where you want to receive official correspondence. Include the city, state, and ZIP code.
- Contact Numbers: Fill in your business telephone and fax numbers in the designated spaces.
Section 4: Business Information
- Federal Employer I.D. Number: Input your unique FEIN issued by the IRS.
- Type Of Ownership: Check the box that matches your business structure: Individual, Partnership, Corporation, or Other (with a description).
- State Tax Accounts: If applicable, provide your account numbers for Kentucky Employer’s Withholding, Corporation Income and License, Sales and Use, and Unemployment Insurance.
Section 5: Provider Type
- Service Category: Select the box corresponding to your primary service: Hospital Services, Nursing Facilities, ICF/MR (Intermediate Care Facility), Home Health Care Agency, Supports for Community Living, or Other.
- License Number: Enter the specific state license number associated with the service category you selected.
- Previous Account: If you have a current or previous Health Care Provider Tax Account Number, list it in the provided field.
Section 6: Owners And Officers (Reverse Side)
- Identification: This section requires details for owners, partners, or officers. For each individual, check the appropriate title (President, Vice President, Secretary, Treasurer, Partner, or Individual).
- Personal Details: Print their full Name, License Number, and Home Address (City, State, ZIP).
- Social Security Number: You must enter the SSN for each listed individual.
- Additional Sheets: If you have more officers or partners than the form allows, attach a separate sheet with the same details.
Section 7: Signature And Certification
- Sign And Date: An authorized owner, partner, or executive officer must sign and date the application to certify the information is correct.
- Contact Info: Provide the signer’s Title, E-mail address, and a direct Telephone Number for follow-up questions.
Section 8: Other Information
- Additional Details: Use the blank lines at the bottom of the form to provide any extra information relevant to your application or registration status.