Michelle p waiver application 2026

1. Click ‘Get Form’ to open the michelle p waiver application in the editor.
2. In Section 1, ensure all fields are filled out completely. Start by legibly printing the applicant's full name, selecting their sex, and entering their Social Security Number (SS#) with exactly 9 digits. If applicable, include the Medical Assistance Number from the Medicaid card.
3. Continue filling out Section 1 by providing the applicant's date of birth in MM/DD/YYYY format, a phone number including area code, and their current address. Make sure to print clearly.
4. If there is a legal representative or guardian for the applicant, complete Section 2. Provide their name, address, phone number, email, county, state, zip code, and relationship to the applicant.
5. In the DSM Diagnosis section, fill out Axis I, II, and III without leaving any blanks. If there is no diagnosis for any axis, write 'none'. Also indicate the age at which the disability was identified.
6. Check all services currently received by the individual in the provided list. This includes options like Home Health and Mental Health Counseling.

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