Kentucky Health Care Reform - Click here to view the home page.
You also may download a Word version of this form and email the completed form to KHBE.
By completing and submitting this form, agent agrees to assist potential Medicaid recipients with their Medicaid application and enrollment and will be required to complete the KHBE Medicaid Training and Exam prior to having access to the benfind system.

*Agent Name


Agency Name

*Business Address







Contact Information

*Office Phone






*DOI Individual Agent License


DOI Insurance Business Entity License