Medicaid Waiver Application printable pdf download

Medicaid Waiver Application

Home and Community Based Services (HCBS)

Complete this form and mail to the BHD Participant Support Specialist.

Waiver Information

Please Check the Appropriate Waiver:

Are you currently on a waiver? ☐ Yes ☐No

Waiver Type: __________________________________

☐ Adult (DD) Waiver

☐ Comprehensive Waiver

If yes, current Case Manager name:

☐ Child (DD) Waiver

☐ Supports Waiver

_____________________________________

☐ Acquired Brain Injury (ABI) Waiver

Applicant Contact Information

Applicant: _____________________________________________________________________ DOB:________/________/________

Last Name

First Name

M.I

Medicaid #: _______ - _______________________

Social Security Number: __________ - _________ - ____________

Gender: ☐Male ☐Female Ethnicity: ____________________ Town to Receive Services: _______________________________

Physical Address:__________________________________________ Mailing Address: _________________________________

City, State, Zip: ______________________________________

City, State, Zip:___________________________________

Phone Number:(______)___________-__________________ E-mail Address:_____________________________________________

Preferred Method of Contact? ☐Mail ☐Phone ☐E-mail

I am interested in the Wyoming Life Resource Center and would like more information. ☐Yes ☐ No

Guardian Contact Information

Please fill out the following section if the person above is under 18 years of age or the person above has

a legal, court-appointed guardian (full or limited).

Name of Parent(s)/Legal Guardian(s): ______________________________________________________________________________

Address: _____________________________________________________ City:_____________________ State: _______ Zip: _____________

E-mail Address: __________________________ Preferred Method of Contact? ☐Mail ☐Phone ☐E-mail

Is this person a legal court-appointed guardian (full or limited)? ☐Yes ☐ No

Emergency Contact Information

Emergency Contact:

Phone: (_______)_________-_________________

____________________________________________________________

Last Name

First Name

Relationship to Participant:___________________________________________________

Address: ______________________________________________________ City: ______________________ State: _______ Zip: ___________

Signatures

_____________________________________________________________________________ Date: _______/______/_______

Signature of Applicant or Legally Responsible Representative

(If Responsible Representative, relationship to the applicant?): □ Parent □ Guardian □ Family Member □ Grandparent □ Other

Signature of Witness___________________________________________________ Date: _______/______/________

(Required if signature is marked with an “X”)

Rev. 4/2014

Medicaid Waiver Application

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