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Blank map 351 form 2025

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The document is a Medicaid Waiver Assessment form used by the Commonwealth of Kentucky's Cabinet for Health and Family Services. It collects comprehensive demographic, eligibility, and health information about Medicaid members applying for various waivers, including Home and Community Based Waivers and Acquired Brain Injury Waivers. The assessment covers areas such as daily living activities, cognitive functioning, behavioral issues, clinical needs, environmental conditions, household information, and additional services received. It aims to evaluate the member's needs to determine appropriate care and support.

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