Get Application For Mr/dd Services - Cowley County

This guide provides clear and supportive instructions for completing the Application For MR/DD Services for Cowley County online. Following each step will help ensure that your application is filled out correctly and submitted without issues.

Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to access and open the application form in an appropriate online format.
2. Begin by entering your personal information. This includes your full name, date of birth, and gender. For gender, select either 'Male' or 'Female' as it applies to you.
3. Indicate your marital status by selecting 'Married' or 'Unmarried'.
4. Input your Social Security number in the designated field. Additionally, provide your Medicaid number if applicable.
5. Fill out the date of your last KAN-BE-Health Screening, if you have had one.
6. Select your race by checking the appropriate box that represents you from the options provided, which include Native American, African American, Asian, Caucasian, Latino, or Other.
7. Choose whether or not you want your name included in the Service Access List by selecting 'Yes' to include your name or 'No' to exclude it. If you do not make a selection, it will be assumed you consent to be included.
8. Review the confirmation statement presented at the end of the application. You will need to certify that all information provided is accurate to the best of your knowledge by signing the form.
9. Complete the section labeled 'Completed By' including the date you filled out the form and provide your telephone number for any further inquiries.
10. Once you have filled out all necessary fields, you can save your changes, download the application, or print it for submission.

Begin your application process online today by following these simple steps.