Get Map 351a Form Waiver Assessment - Kentucky - Chfs Ky

The MAP 351A Form is crucial for individuals seeking Medicaid waiver services in Kentucky. This guide provides a step-by-step instruction on how to complete this form online, ensuring that all essential details are accurately captured.

Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to access the MAP 351A Form Waiver Assessment and open it in the online editor.
2. Begin by entering the member's demographics in Section I. Fill in the name, Medicaid Member ID number, date of birth, county code, sex, and marital status. Also, provide emergency contact information and member's height and weight.
3. In Section II, choose the type of program applied for by checking the appropriate boxes. Proceed to enter the start and end dates for the certification period.
4. Provide the member's primary diagnosis and any associated ICD-9 or DSM codes. This information is critical for processing the waiver assessment.
5. In Section III, fill out the assessment provider's details, including their name, provider number, and contact information.
6. In Section IV, complete the self-assessment questions related to community inclusion, relationships, rights, dignity and respect, health, and lifestyle. This section may require additional pages if necessary.
7. Complete Section V where you will assess the member's independence in activities of daily living, such as dressing, grooming, and bathing. Provide comments if additional assistance is required.
8. For Section VI, evaluate the member's capability to perform instrumental activities of daily living like meal preparation, shopping, and handling finances.
9. In Sections VII to XII, provide detailed information regarding the member’s neuro/emotional/behavioral status, clinical information, household dynamics, and any additional services they receive.
10. Finalize the form by completing Section XIII, ensuring all signatures and dates are correctly entered. This verifies that the assessment has been completed and submitted.
11. After completing the form, you can save changes, download a copy, print it, or share it as needed.

Begin filling out the MAP 351A Form Waiver Assessment online now to ensure timely processing of your Medicaid waiver request.