Kentucky Form Map 351 – Fill Out and Use This PDF

The Kentucky Map 351 form, officially known as the Medicaid Waiver Assessment form, is a critical document used by the Commonwealth of Kentucky's Cabinet for Health and Family Services, particularly by the Department for Medicaid Services. It meticulously captures essential information, ranging from member demographics to comprehensive assessments of an individual’s eligibility for different Medicaid waiver programs, such as Home and Community Based Waiver, Acquired Brain Injury Waiver, and several others. This form aids in ensuring that members receive appropriate care tailored to their unique needs. To ensure a seamless process in obtaining necessary Medicaid waiver benefits, make sure to accurately fill out the Kentucky Map 351 form by clicking the button below.

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Kentucky Form Map 351 PDF Details

In the dynamic landscape of healthcare and support services, navigating the intricacies of Medicaid waivers requires a comprehensive understanding of various forms and procedures. The Kentucky MAP 351 form serves as a critical tool in this process, structured to gather essential information for individuals seeking Medicaid Waiver services in Kentucky. This form, revised in July 2008 by the Commonwealth of Kentucky’s Cabinet for Health and Family Services’ Department for Medicaid Services, meticulously captures a wide range of data. From demographic details to the acute assessment of an individual's daily living capabilities, the Kentucky MAP 351 form is structured into several sections that cover member demographics, waiver eligibility, self-assessment, activities of daily living, instrumental activities of daily living, and neuro/emotional/behavioral assessments. It also emphasizes the importance of understanding the member’s community inclusion, relationships, rights, dignity, health, and lifestyle aspirations, thus, providing a holistic view of the individual's needs and preferences. The detailed nature of this form facilitates a thorough evaluation process, ensuring that Medicaid members receive the most appropriate and tailored support to enhance their quality of life.

Question	Answer
Form Name	Kentucky Form Map 351
Form Length	15 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 45 sec
Other names	ICD-9, DSM, map 351, ky map 351

Form Preview Example

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

Department for Medicaid Services

MEDICAID WAIVER ASSESSMENT

SECTION I – MEMBER DEMOGRAPHICS

Name (last, first, middle)

Date of birth (mo., day, yr.)

Medicaid Member ID #

Street address

County code

Sex (check one)

Marital status (check one)

Male

Divorced

Married

Separated

Female

Single

Widowed

City, state and zip code

Emergency contact (name)

Emergency contact (phone #)

Member phone number

Is member able to read and

Member’s height

write

Yes

Member’s weight

SECTION II – MEMBER WAIVER ELIGIBILITY

Type of program applied for (CHECK ONE)

Adjudicated

/Nonadjudicated

_____

Home and Community Based Waiver

Type of application (check one)

Acquired Brain Injury Waiver

Certification

Re-certification Re-application

Acquired Brain Injury/Long Term Care Waiver

Supports for Community Living Waiver

Michelle P. Waiver

Consumer Directed Option Blended

Member admitted from (check one)

Certification period (enter dates below)

Home Hospital Nursing facility

ICF/MR/DD

Begin date

End date

Other:

Certification

number:

Has member’s freedom of choice been explained and

Has member been informed of the process to make

verified by a signature on the MAP 350 Form Yes

a complaint

Yes

No (see instructions)

Physician’s name

Physician’s license number

Physician’s phone number

(enter 5 digit #)

Enter member’s primary diagnosis: HCB (ICD-9 code); SCL (DSM code); ABI (ICD-9 and/or DSM)

Enter all diagnoses including DSM or ICD-9 codes:

Is the member diagnosed with one of the following?

AXIS I: (mental illness)

Mental Retardation/ IQ=

(Date-of-onset

)

Developmental Disability

AXIS II: (MR/DD)

(Date-of-onset

)

Mental Illness

(Date-of-onset

)

AXIS III: (Medical)

Brain Injury

Cause of Brain Injury:

Date of Brain Injury:

Rancho Scale

SECTION III – ASSESSMENT PROVIDER INFORMATION

Assessment/Reassessment provider

Provider number

Provider phone number

name:

Street address

City, state and zip code

Provider contact person

Page 1 of 15

MAP 351		Commonwealth of Kentucky
(Rev. 7/08)		Cabinet for Health and Family Services
		Department for Medicaid Services
		MEDICAID WAIVER ASSESSMENT

	NAME (LAST, FIRST)		MEDICAID NUMBER

		SECTION IV SELF ASSESSMENT
		*For SCL, MP and ABI waivers only	*add additional pages as needed

Community Inclusion (what do you like to do or where would you like to go in the community, where do you go for recreation, do you not get to go somewhere that you would like to)

Relationships (How do you stay in contact with your friends and family, do you need assistance in making or keeping friends, who are your friends)

Rights (do you understand your rights, are any of your rights restricted, do you know what is abuse or neglect)

Dignity and Respect (how are you treated by staff, do you have a place you can go to be with friends or to be alone or have privacy)

Health (who are your doctors ,do you have any health concerns, what medicine do you take, how do they make you feel,)

Lifestyle (do you have a job, do you want to work, do you want to go to school, do you go to the bank, do you have spending money to carry)

Page 2 of 15

MAP 351			Commonwealth of Kentucky
(Rev. 7/08)			Cabinet for Health and Family Services
			Department for Medicaid Services
			MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)				Medicaid Number

			SECTION V – ACTIVITIES OF DAILY LIVING
	1) Is member independent with			Comments:
	dressing/undressing
	Yes	No(If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires hands-on assistance with upper body
	Requires hands-on assistance with lower body
	Requires total assistance

	2) Is member independent with grooming			Comments:
	Yes	No(If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires hands-on assistance with
	oral care		shaving
	nail care		hair
	Requires total assistance

	3) Is member independent with bed mobility			Comments:
	Yes	No (If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Occasionally requires hands-on assistance
	Always requires hands-on assistance
	Bed-bound
	Required bedrails

	4) Is member independent with bathing			Comments:
	Yes	No (If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires hands-on assistance with upper body
	Requires hands-on assistance with lower body
	Requires Peri-Care
	Requires total assistance

	5) Is member independent with toileting			Comments:
	Yes	No (If no, check below all that apply and comment)
	Bladder incontinence
	Bowel incontinence
	Occasionally requires hands-on assistance
	Always requires hands-on assistance
	Requires total assistance
	Bowel and bladder regimen

	6) Is member independent with eating Yes No			Comments:
	(If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires assistance cutting meat or arranging food
	Partial/occasional help
	Totally fed (by mouth)
	Tube feeding (type and tube location)

Page 3 of 15

MAP 351				Commonwealth of Kentucky
(Rev. 7/08)				Cabinet for Health and Family Services
				Department for Medicaid Services
				MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)					Medicaid Number

	7) Is member independent with ambulation					Comments:
	Yes	No (If no, check below all that apply and comment)
	Dependent on device
	Requires aid of one person
	Requires aid of two people
	History of falls (number of falls, and date of last fall)

	8) Is member independent with transferring					Comments:
	Yes	No (If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Hands-on assistance of one person
	Hands-on assistance of two people
	Requires mechanical device
	Bedfast

			SECTION VI - INSTRUMENTAL ACTIVITIES OF DAILY LIVING
	1) Is member able to prepare meals			Yes	No		Comments:
	(If no, check below all that apply and explain in the comments)
	Arranges for meal preparation
	Requires supervision or verbal cues
	Requires assistance with meal preparation
	Requires total meal preparation
	2) Is member able to shop independently				Yes No		Comments:
	(If no, check below all that apply and explain in the comments)
	Arranges for shopping to be done
	Requires supervision or verbal cues
	Requires assistance with shopping
	Unable to participate in shopping

	3) Is member able to perform light housekeeping						Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for light housekeeping duties to be performed
	Requires supervision or verbal cues
	Requires assistance with light housekeeping
	Unable to perform any light housekeeping

	4) Is member able to perform heavy housework						Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for heavy housework to be performed
	Requires supervision or verbal cues
	Requires assistance with heavy housework
	Unable to perform any heavy housework

Page 4 of 15

MAP 351			Commonwealth of Kentucky
(Rev. 7/08)			Cabinet for Health and Family Services
			Department for Medicaid Services
			MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)				Medicaid Number

	5) Is member able to perform laundry tasks				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for laundry to be done
	Requires supervision or verbal cues
	Requires assistance with laundry tasks
	Unable to perform any laundry tasks

	6) Is member able to plan/arrange for pick-up,				Comments:
	delivery, or some means of gaining possession of
	medication(s) and take them independently
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for medication to be obtained and taken correctly
	Requires supervision or verbal cues
	Requires assistance with obtaining and taking medication
	correctly
	Unable to obtain medication and take correctly

	7) Is member able to handle finances independently				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for someone else to handle finances
	Requires supervision or verbal cues
	Requires assistance with handling finances
	Unable to handle finances

	8) Is member able to use the telephone independently				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Requires adaptive device to use telephone
	Requires supervision or verbal cues
	Requires assistance when using telephone
	Unable to use telephone
		SECTION VII-NEURO/EMOTIONAL/BEHAVIORAL
	1) Does member exhibit behavior problems			Comments:
	Yes	No (If yes, check below all that apply and explain		Date of functional analysis:		and/or
	the frequency in comments)			Date of behavior support plan:
	the frequency in comments)
	Disruptive behavior
	Disruptive behavior
	Agitated behavior
	Assaultive behavior
	Self-injurious behavior
	Self-neglecting behavior

Page 5 of 15

How to Edit Kentucky Form Map 351 Online for Free

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This PDF form will require particular data to be filled out, thus you need to take whatever time to type in precisely what is asked:

1. When filling in the DSM, make certain to include all of the needed blank fields in its corresponding section. It will help speed up the process, allowing for your details to be handled without delay and properly.

map351 writing process explained (part 1)

2. Soon after filling in the previous section, go on to the next part and enter the necessary particulars in all these fields - Certification period enter dates, Physicians license number enter, Has members freedom of choice been, Mental Retardation IQ Dateofonset, Is the member diagnosed with one, Physicians phone number, Cause of Brain Injury Date of, SECTION III ASSESSMENT PROVIDER, AssessmentReassessment provider, Provider number, City state and zip code, Provider phone number, and Provider contact person.

3. The following segment is typically rather uncomplicated, Name last first, Medicaid Number, For SCL MP and ABI waivers only, SECTION IV SELF ASSESSMENT, and Community Inclusion what do you - all these fields will have to be completed here.

For SCL MP and ABI waivers only, Community Inclusion what do you, and Medicaid Number of map351

4. Completing Community Inclusion what do you is paramount in the next section - be sure to spend some time and take a close look at every single empty field!

Community Inclusion what do you, Community Inclusion what do you, and Community Inclusion what do you in map351

5. And finally, this last section is precisely what you need to wrap up before closing the document. The blank fields at this point are the following: Name last first, Medicaid Number, SECTION V ACTIVITIES OF DAILY, Comments, Is member independent with, dressingundressing Yes NoIf no, Is member independent with, Yes NoIf no check below all that, Requires handson assistance with, oral care nail care Requires total, shaving hair, Is member independent with bed, Yes No If no check below all that, Is member independent with bathing, and Yes No If no check below all that.

map351 conclusion process outlined (part 5)

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Kentucky Form Map 351 – Fill Out and Use This PDF

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