Medicaid Waiver Application


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
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: ___________
_____________________________________________________________________________ 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


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