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Get KY MAP 14 2018-2024

______________________ (Print Your Name) (Print Authorized Representative’s Name) to help me as I have chosen below with Medicaid. This authorization is valid from the date of applicant’s signature until the form is rescinded by the applicant. I give my permission for the person named above as my authorized representative to (please check all that apply): Apply, Report Changes Apply, Report Changes, Recertify Apply, Report Changes, Recertify and receive a copy of Notices I understand that I .

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