Kentucky form map medicaid waiver 2026

1. Click ‘Get Form’ to open the Kentucky Form MAP Medicaid Waiver in the editor.
2. Begin with Section I – Member Demographics. Fill in the member's name, Medicaid Member ID, date of birth, and address. Ensure you check the appropriate boxes for sex and marital status.
3. Proceed to Section II – Member Waiver Eligibility. Select the type of program applied for and provide details about the member’s freedom of choice and complaint process understanding.
4. In Section III, enter Assessment Provider Information including provider name, number, and contact details.
5. Continue through Sections IV to XII, providing detailed responses regarding daily living activities, clinical information, household information, and any additional services received.
6. Finally, ensure all signatures are completed in Section XIII before saving your document.

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