Type of Program Applied for (check one): Home and Community Based Waiver, Acquired Brain Injury Waiver, Acquired Brain Injury/Long Term Care Waiver or Michelle P Waiver.
Type of Application: check one: Certification, Re-certification or Re-application.
Participant Directed Services: if the member has chosen Participant Directed Services, include form MAP 2000.
Signatures: the person(s) performing the assessment or reassessment sign with title and date.
Program Delivery: check one: Participant Directed Services, Traditional or Blended.
| Question | Answer |
|---|---|
| Form Name | MAP 351 |
| Form Length | 15 pages |
| Fillable? | Yes |
| Fillable fields | 633 |
| Avg. time to fill out | 60+ min |
| Edition | 4/20 |
| Issuing agency | Kentucky Cabinet for Health and Family Services, Department for Medicaid Services |
| Other names | MAP 351, MAP-351, MAP351, Form MAP 351, Kentucky MAP 351, Medicaid Waiver Assessment |
| Official source | MAP 351 (Rev 4/20), Kentucky Cabinet for Health and Family Services |
Kentucky Form Map 351 isn’t the one you’re looking for?