Get Map 10 Form

Filling out the Map 10 Form online is a straightforward process that ensures you provide all necessary information for waiver services. This guide will walk you through each component of the form, making it easy for users at all experience levels to complete it accurately.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the Map 10 Form and open it in the editor.
2. Begin by entering the requestor’s information in the designated fields. This includes the requestor’s name, address, city, zip code, and phone number. Ensure all details are accurate.
3. Next, provide the member's details by entering their name and Medicaid Member ID number in the specified areas. Additionally, fill in the member's address, city, zip code, and phone number.
4. Document the diagnosis or diagnoses in the designated section. It is important to provide clear and precise information as this impacts eligibility for waiver services.
5. Select the recommended waiver program by checking the appropriate box for either Home and Community-Based Waiver, ABI Waiver, ABI Long Term Care Waiver, SCL Waiver, or Michelle P. Waiver. Ensure the selected option aligns with the member's needs.
6. The authorized person must sign the form in the 'Authorized Signature' area and include their NPI number. Also, complete the authorized person’s address, city, zip code, and phone number.
7. Finally, enter the date of completion in the provided space before saving your changes. Users can then choose to download, print, or share the completed Map 10 Form as needed.

Complete and submit your Map 10 Form online today to ensure timely processing of waiver services.