Form MAP 14 at a glance
What it is: This is the Commonwealth of Kentucky Cabinet for Health and Family Services, Department for Medicaid Services AUTHORIZED REPRESENTATIVE form.
A filled-in Form MAP 14 example: an applicant names an authorized representative
How to fill out Form MAP 14, box by box
Tap a group of boxes to open it, and a picture to see it full size.
I have asked
I have asked (Print Your Name) (Print Authorized Representative's Name) to help me as I have chosen below with Medicaid. This authorization is valid from the date of applicant's signature until the form is rescinded by the applicant.
Permission (check all that apply)
Under I give my permission for the person named above as my authorized representative to, check all that apply.
Check the box for Apply, Report Changes, Recertify.
Check the box for Apply, Report Changes, Recertify and receive a copy of Notices.
Applicant/Member and Authorized Representative
Write the Printed Applicant/Member Name and the Printed Authorized Representative Name, sign the Applicant/Member Signature and Authorized Representative Signature lines, write the Applicant/Member Address and Authorized Representative Address with City, State, Zip for each, the Phone Number for each, and the Date Signed for each.
Witness, Email Address, Relationship or Company Name
If signed by X, a Witness signs on the Witness line; write the Email Address and the Relationship or Company Name.
I understand
Complete and truthful information
I understand that I or my authorized representative, must provide complete and truthful information to have my Medicaid eligibility determined or redetermined. My authorized representative is responsible for fulfilling all responsibilities designated above as well as agreeing to maintain the confidentiality of any information regarding the applicant or member provided by the agency.
False information
If I or my authorized representative knowingly provides false information or withholds information, I may be subject to prosecution for fraud.
Eligibility determinations
Eligibility determinations may take up to 30 days from the date of application to be completed.
Identification cards and letters
All identification cards and letters will be mailed to the address you choose.
Show your identification card
You will need to show your identification card to your medical providers so they can bill Medicaid for the services you received.
Sources
[1] Form MAP 14 (10/21), Department for Medicaid Services Authorized Representative, Commonwealth of Kentucky Cabinet for Health and Family Services (the Official source link on this page).