Form Map 621 – Fill Out and Use This PDF

The MAP-621 form serves as an application for individuals seeking to join the waiting list for the Medicaid Participant Directed Waiver (MPW). This form gathers essential information, including personal identification, medical details, and any current services received, to assess eligibility and needs. To ensure a successful application, it is crucial that no section is left blank, as incomplete submissions will be returned.

If you or someone you know is in need of the MPW waiver, consider taking the first step by filling out the MAP-621 form accurately. For ease and convenience, click the button below to begin the process.

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Form Map 621 PDF Details

Navigating the intricate pathways of healthcare and support services can be a formidable challenge, especially for individuals in need of specialized services such as those provided under the Medicaid waiver programs. TheMAP-621 form, a critical document issued by the Cabinet for Health and Family Services Department for Medicaid Services, serves as a gateway for many to access the Michelle P. Waiver (MPW) waiting list. It is meticulously designed to collect comprehensive details about the applicant, encompassing everything from personal identification to medical diagnoses and the type of services currently received. This form demands precise attention to detail, insisting that no part of section 1 should be left blank, mandating the legible printing of the applicant's name, the inclusion of a Social Security number, a Medicaid assistance number if available, and other core details such as date of birth, phone number, and current address. For applicants with legal representatives or guardians, section 2 provides space to enter pertinent information, strengthening the application by ensuring all necessary legal and guardian details are explicitly provided. Additionally, the form takes a deep dive into the medical history of the individual, requiring details of DSM diagnoses and the identification of any intellectual, developmental, or physical disabilities, thereby painting a complete picture of the applicant's needs. Lastly, it outlines the services currently being received by the individual, which could range from acquired brain injury support to various therapies and residential or community-based services, underscoring the comprehensive nature of this application in guiding the allocation of vital resources under the MPW waiver. By submitting this form, individuals embark on the process towards receiving much-needed support, marking a critical step in navigating the complex health care landscape.

Question	Answer
Form Name	Form Map 621
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	MPW, michelle p waiver person, DOB, Carewise

Form Preview Example

MAP-621 (2/14)	Cabinet for Health and Family Services
	Department for Medicaid Services
	APPLICATION FOR MPW WAIVER WAITING LIST

Section 1

DO NOT leave any information blank in section 1. Applications will be returned if left blank. Name - Legibly print first, middle and last name of applicant

Sex - Check whether the applicant is male or female SS# - Be sure the social security number has 9 numbers

Medical Assistance Number - This is the # on the MEDICAID card (10 numbers) If applicant has not applied for Medicaid then enter N/A

DOB - example: 08/18/1966

Phone Number - Always include area code. If no phone, please write “no phone” Current Address - Please print legibly.


Name:					Sex:
	First	Middle		Last
Social Security Number:			Medical Assistance Number:
Date of Birth:				Phone:
	Month, Day Year
Current Address:

City

County

State

Zip Code

Section 2

Complete this section only if there is a LEGAL representative or guardian

If the applicant is a minor, there must be a legal guardian.

Legal Representative/Guardian:

Address

	City	County	State	Zip Code
Phone:		Relationship to Applicant:
Email:			Ex: mother, father, friend

DSM Diagnosis

Axis I – DO NOT LEAVE BLANK - write “none” on the line if there is no diagnosis Axis II - DO NOT LEAVE BLANK - write “none” on the line if there is no diagnosis Axis III - DO NOT LEAVE BLANK - write “none” on the line if there is no diagnosis

Age disability identified is the age the applicant was diagnosed with an intellectual or developmental disability (Ex: birth, 1 yr old, etc.). Intellectual disability must be present prior to age 18. Developmental disability must be present prior to age 22.

DSM Diagnosis:

Axis I (Mental Health):

Axis II (Intellectual/Developmental Disability):

Axis III (Physical Health):

Age Disability Identified:

PAGE 1

MAP-621 (2/14)	Cabinet for Health and Family Services
	Department for Medicaid Services


SERVICES THE INDIVIDUAL CURRENTLY RECEIVES (Check ALL THAT APPLY)
Acquired Brain Injury	Home Health	School Services
Behavior Support	Mental Health Counseling/Medication	Speech Therapy
Case Management	Supported Employment
Day Program	Occupational Therapy
EPSDT (if under 21)	Physical Therapy
Hart Supported Living	Residential
Home & Community Based Waiver	Respite
Other Medicaid Services:
Other:

Mail or Fax to:

Carewise Health

9200 Shelbyville Road. Suite 800

Louisville, KY 40222

Fax: 1-800-807-7840

PAGE 2

How to Edit Form Map 621 Online for Free

You can fill in DSM without difficulty with the help of our PDF editor online. Our tool is constantly evolving to present the best user experience achievable, and that's due to our dedication to continuous enhancement and listening closely to feedback from customers. All it takes is just a few easy steps:

Step 1: Access the PDF doc in our tool by clicking on the "Get Form Button" above on this webpage.

Step 2: After you start the tool, you will see the form prepared to be filled in. Aside from filling in different blank fields, you could also perform various other actions with the form, that is adding custom text, changing the initial textual content, inserting graphics, signing the document, and much more.

To be able to finalize this PDF document, be sure to enter the right information in every single field:

1. To begin with, while completing the DSM, begin with the section that includes the following fields:

Filling in section 1 in michelle p waiver person

2. Now that the last section is completed, you need to insert the essential specifics in Age disability identified is the, and Page so you can progress further.

Completing section 2 of michelle p waiver person

3. This next part will be focused on SERVICES THE INDIVIDUAL CURRENTLY, Home Health Mental Health, School Services Speech Therapy, Acquired Brain Injury Behavior, and Other Mail or Fax to Carewise - fill out every one of these blanks.

SERVICES THE INDIVIDUAL CURRENTLY, Other Mail or Fax to Carewise, and Acquired Brain Injury Behavior inside michelle p waiver person

Regarding SERVICES THE INDIVIDUAL CURRENTLY and Other Mail or Fax to Carewise, be sure that you review things in this section. Those two could be the most important ones in this page.

Step 3: Soon after double-checking the filled in blanks, press "Done" and you're done and dusted! After registering a7-day free trial account with us, you'll be able to download DSM or email it directly. The PDF document will also be at your disposal through your personal account with your every modification. FormsPal ensures your information confidentiality by having a protected system that never records or distributes any type of private data involved. Be confident knowing your files are kept protected when you work with our tools!

Form Map 621 – Fill Out and Use This PDF

Form Map 621 PDF Details

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How to Edit Form Map 621 Online for Free

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