Form Map 14 Kentucky PDF Details

In the intricate landscape of healthcare and public assistance, the Commonwealth of Kentucky Cabinet for Health and Family Services has developed a pivotal tool to ensure that all individuals have the opportunity to apply for Medicaid, irrespective of their ability to physically present themselves at a Department for Community Based Services (DCBS) office. The MAP 14 form, a critical document within this framework, serves as a bridge to accessibility and inclusivity, allowing individuals to designate an authorized representative to apply for Medicaid on their behalf. This authorization, valid for a 90-day period from the date of the applicant's signature, acknowledges various circumstances that may prevent direct application, offering a solution through delegation. The form meticulously outlines the necessity for complete and truthful information in the eligibility determination process, warning of the legal repercussions of fraud. Furthermore, it stipulates a timeline for the determination of eligibility, ensuring applicants are aware of the procedural timeframe. The MAP 14 form not only facilitates a smoother application process but also emphasizes the importance of accessible healthcare services, underscoring the Kentucky Cabinet for Health and Family Services' commitment to serving its community's needs. The procedural specifics, including the roles and responsibilities of both the applicant and the authorized representative, are clearly communicated within the document, providing a transparent overview of the application process and reiterating the importance of accuracy and honesty in the pursuit of Medicaid benefits.

QuestionAnswer
Form NameForm Map 14 Kentucky
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesky map14, ky map 14 form, dcbs map 14 ky, get the ky map 14 form

Form Preview Example

MAP 14 (1/09)

Commonwealth of Kentucky

Cabinet for Health and Family Services

Department for Medicaid Services

AUTHORIZED REPRESENTATIVE

If you can not come to the office and apply for Medicaid, you may call the Department for Community Based Services (DCBS) office in the county where you live and other arrangements may be made. If you want someone to make an application for you, please fill out the information below.

I ____________________________________ have asked ___________________________________

(Print Your Name)

(Print Authorized Representative’s Name)

to apply for Medicaid for me. This authorization is valid for 90 days from the date of applicant’s signature.

I give my permission for the above person to apply for Medicaid for me because I can not come to the local office of the Department for Community Based Services (DCBS) and do not want other arrangements to be made. I can not come to the DCBS office because:

__________________________________________________________________________________

__________________________________________________________________________________

I understand that I or my authorized representative must provide complete and truthful information to have my Medicaid eligibility determined.

If I or my authorized representative knowingly provides false information or withholds information I may be subject to prosecution for fraud.

Eligibility determinations may take up to 30 days from the date of application to be completed. DCBS will contact you to confirm information provided by your authorized representative. All identification cards and letters will be mailed to your address. You will need to show your identification card to your medical providers so they can bill Medicaid for the services you received.

Your Signature

 

Authorized Representative Signature

 

 

 

Address

 

Address

 

 

 

City/State/Zip

 

City/State/Zip

 

 

 

Phone number

 

Phone number

 

 

 

Date

 

Date

Witness (if signed by an X)

Company Name (if Appropriate)/Relationship

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ky map 14 form writing process detailed (step 1)

2. After this section is completed, you need to add the necessary specifics in Eligibility determinations may, Your Signature, Address, CityStateZip, Phone number, Date, Authorized Representative Signature, Address, CityStateZip, Phone number, Date, Witness if signed by an X, and Company Name if so you're able to move forward further.

ky map 14 form completion process clarified (step 2)

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