Map 14 form 2026

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4.8 out of 5

124 votes

The document is a Medicaid application authorization form from the Commonwealth of Kentucky's Department for Medicaid Services. It allows individuals who cannot visit the local office to designate an authorized representative to apply for Medicaid on their behalf. The authorization is valid for 90 days, and it emphasizes the importance of providing truthful information to avoid fraud. Eligibility determinations may take up to 30 days, and all correspondence will be sent to the applicant's address.

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Click ‘Get Form’ to open the map 14 form in the editor.
Begin by entering your name in the designated field where it states 'I _________ have asked'. This identifies you as the applicant.
Next, fill in the name of your authorized representative in the space provided. This person will be applying for Medicaid on your behalf.
In the section explaining why you cannot visit the DCBS office, provide a brief but clear explanation of your circumstances.
Ensure both you and your authorized representative sign and date the form at the bottom. Include addresses and phone numbers as required.
If applicable, have a witness sign next to your signature, especially if you are signing with an 'X'.

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Versions	Form popularity	Fillable & printable
2003	4.8 Satisfied (124 Votes)

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