Map-23 Home And Community Based Waiver Services Selection Of Provider Form
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1Commonwealth of Kentucky
Cabinet for Health and Family Services
Department for Medicaid Services
HOME AND COMMUNITY BASED WAIVER SERVICES
SELECTION OF PROVIDER FORM
Section I: HCB Waiver Member Demographics (
)
Please print clearly
Name (Last, First, Middle): _______________________________________________________________
Date of Birth: (__ __ / __ __/ __ __ __ __)
County of Residence: _______________________
Medicaid Identification Number (MAID): __ __ __ __ __ __ __ __ __ __ (10 digits)
Street: ___________________________________________________________________________________
City: ___________________________________
State: ___________ Zip Code: _____________________
Member’s Telephone #: (_______) __________________ Alternate Telephone #: (______) ________________
Representative’s Name & Telephone #: __________________________________(______) _______________
Section II: Selection of Provider for Reassessment Service (
)
Please print clearly
Current Reassessment Provider’s Name & Telephone #: _______________________________(______) _____________
Agency’s Name: ________________________ ___________________ Provider #: ______________________________
I understand that I have the freedom to choose who will provide my HCB Waiver reassessment service. Effective
____/____/________,
I
select
__________________________________________________
to
provide
my
reassessment service. I further understand that I am required to update this provider selection form at any time I
decide to select a new reassessment provider. I also understand that I have a right to receive a copy of this form
and have it explained to me.
Selected Agency’s Name: ________________________ _____________________ Provider #: __________ __________
Agency’s address: ________________________________________________ Telephone #: (______) ______________
Section III: Selection of Provider for Case Management Services (
)
Please print clearly
Current Case Manager’s Name & Telephone #: ______________________________________(______) ______________
Agency’s Name: __________________________________________________ Provider #: ________________________
I understand that I have the freedom to choose who will provide my HCB Waiver case management services.
Effective ____/____/________, I select _________________________________________________ to provide my case
management services.
I further understand that I am required to update this provider selection at any time I
decide to select a new case management provider. I also understand that I have a right to receive a copy of this
form and have it explained to me.
Selected Agency’s Name: ________________________ _____________________ Provider #: __________ __________
Agency’s address: ________________________________________________ Telephone #: (______) ______________
Section IV: Authorized Signatures
I have read the above information or had the information read to me and my questions were answered to my
satisfaction.
Member’s or Representative’s Signature: __________________________________ Date: ______________
As the Current Case Manager, I have fully explained the above information and have provided a copy of this form to
the Member and/or the Member’s Representative.
Case Manager’s Signature: ___________________________________________ Date: _________________
Note: The current Case Manager must submit a copy of the MAP-23 to the PRO and to the selected provider(s) indicated above with
every requested change and anytime the MAP 109-HCBW is completed/modified.
MAP-23
(7/2005)
Clear Form
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