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  • Map 24

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) FROM: (Nursing Facility/Waiver Agency) (Provider Number) DATE: SUBJECT: (Recipient Name) (Social Security Number) (Previous Address) (City) (State) (ZIP) (Responsible Relatives Name) (Street Address) (City) (State) (ZIP) This is to notify you that the above referenced recipient: was admitted to this nursing facility/waiver agency on is in Title (Date) (XVIII or XIX) Placement Status, and was placed in a: Nursing Facility Bed ICF/ /DD Bed Mental Hospital Bed EPSDT Bed Home and Co.

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How to fill out the Map 24 online

The Map 24 form is essential for notifying relevant parties about the admission and discharge status of individuals in various care facilities in Kentucky. This guide provides step-by-step instructions to help users accurately complete the Map 24 online.

Follow the steps to complete the Map 24 form with ease.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Enter the date in the designated field to indicate when the recipient was admitted to the nursing facility or waiver agency.
  3. Select the appropriate Title placement status (XVIII or XIX) by clicking on the corresponding option.
  4. Choose the type of facility the recipient is placed in by marking one of the provided options, such as Nursing Facility Bed, ICF/DD Bed, Mental Hospital Bed, EPSDT Bed, etc.
  5. If applicable, fill in the information for Home and Community Based Waiver Services or other specific service categories as required.
  6. Input the discharge date if the recipient has been discharged, along with the name and address of the new nursing facility or waiver agency.
  7. Indicate if the individual expired or was returned to HCBW or Michelle P. waiver services within 60 days by including the relevant dates.
  8. For HCBW and Michelle P. waiver clients, enter the last service date provided in the corresponding field.
  9. Sign the form in the designated signature area to validate the information provided.
  10. Once all sections are completed, save changes, and consider downloading, printing, or sharing the completed form as needed.

Complete your Map 24 form online with confidence today.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232