MAP 14 414 Commonwealth of Kentucky Cabinet for Health and - chfs ky 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your name in the designated field where it states 'I __________ have asked'. This identifies you as the applicant.
3. Next, enter the name of your authorized representative in the field labeled 'to apply for Medicaid for me'. This person will act on your behalf.
4. In the section that asks why you cannot come to the DCBS office, provide a brief explanation. This is important for understanding your situation.
5. Sign the form where indicated, ensuring that both you and your authorized representative complete their respective signature fields.
6. Fill out all address and contact information accurately to ensure proper communication regarding your application.
7. If applicable, have a witness sign where indicated if you are unable to sign yourself.

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