The Map 14 Kentucky form is an essential document used for granting permission to an authorized representative to apply for Medicaid on behalf of an individual who is unable to do so themselves. This form ensures that the application process can continue smoothly, even when personal circumstances prevent direct involvement. By filling out this form, individuals can ensure their healthcare needs are addressed while complying with the necessary legal requirements.
The Map 14 Kentucky form plays a crucial role in the Medicaid application process for individuals who may be unable to visit their local Department for Community Based Services (DCBS) office. Designed for those who need assistance, this form allows applicants to authorize a representative to submit their Medicaid application on their behalf. By filling out the necessary information, individuals can designate someone they trust to handle the application, ensuring that their needs are addressed even if they cannot attend in person. This authorization remains valid for 90 days, providing ample time for the application process to unfold. It is essential for both the applicant and the authorized representative to understand that providing complete and truthful information is vital for determining Medicaid eligibility. Failure to do so could lead to serious consequences, including potential prosecution for fraud. Once the application is submitted, eligibility determinations may take up to 30 days, during which the DCBS will verify the information provided. All correspondence, including identification cards, will be mailed directly to the applicant’s address, emphasizing the importance of keeping contact information updated. This form not only streamlines the application process but also empowers individuals to seek the healthcare assistance they need through a trusted representative.
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
City/State/Zip
Phone number
Date
Witness (if signed by an X)
Company Name (if Appropriate)/Relationship
Ky State Tax - It contains a section for Kentucky Use Tax on out-of-state purchases, ensuring compliance with state tax laws on internet and mail orders.
A Texas Last Will and Testament form is a legal document that outlines how a person's assets will be distributed after their death. This form ensures that your wishes are honored and provides clarity for your loved ones during a difficult time. For further assistance, you can find valuable resources at Texas Documents. To get started on securing your legacy, fill out the form by clicking the button below.
Kentucky Elevator Mechanic License - The license fee is determined using a specified chart, taking into account the applicant's birth month and the month of application, ensuring accurate proration of the initial fee.