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Get KY MAP-14 2003-2024

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 Commun.

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