Map 14 2026

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4.9 out of 5

42 votes

The document is a Medicaid Authorized Representative form from the Commonwealth of Kentucky, allowing an individual to designate another person to assist with their Medicaid application and management. It outlines the responsibilities of both the applicant and the authorized representative, including the need for truthful information and confidentiality. The authorization remains valid until rescinded by the applicant.

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Click ‘Get Form’ to open map 14 in the editor.
Begin by entering your name in the first blank field, where it states 'I _________'. This identifies you as the applicant.
In the next field, print the name of your authorized representative. This person will assist you with Medicaid-related tasks.
Select the appropriate permissions for your authorized representative by checking all applicable boxes. Options include 'Apply, Report Changes', 'Recertify', and 'Receive a copy of Notices'.
Ensure that both you and your authorized representative sign in the designated signature fields to validate this authorization.
Fill in your address and contact information, as well as that of your authorized representative, ensuring accuracy for correspondence.
Finally, review all entries for completeness and correctness before submitting the form through our platform.

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Versions	Form popularity	Fillable & printable
2018	4.9 Satisfied (42 Votes)
2014	4 Satisfied (59 Votes)
2009	4 Satisfied (49 Votes)

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ky map 14

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