Form Map-4100a - Acquired Brain Injury Waiver Program Provider Information And Services
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1MAP- 4100A
ACQUI RED BRAI N I NJURY WAI VER PROGRAM PROVI DER
(Rev. 09/2010)
I NFORMATI ON AND SERVI CES
PROVIDER NUMBER ________________________________________________________________________
NPI (National Provider Identifier) Number:________________________________________________________
AGENCY NAME: ___________________________________________________________________________
AGENCY ADDRESS: ________________________________________________________________________
CITY _____________________________________________ STATE __________ ZIP CODE ______________
COVERED SERVICES (Check all that apply)
ABI WAIVER
ABI LONG TERM CARE WAIVER
Case Management
Case Management
Personal Care Services
Community Living Supports
Respite Care Services
Respite Care Service
Companion Care Services
Adult Day Health Care
Adult Day Training
Adult Day Training
Supported Employment Services
Supported Employment Services
Behavior Programming
Behavior Programming
Psychological Rehab Services
Psychological Rehab Services
Therapeutic Activities/Occupational Therapy
Therapeutic Activities/Occupational Therapy
Speech, Hearing and Language Services
Speech, Hearing and Language Services
Durable Medical/ Specialized Medical Equipment
Durable Medical/ Specialized Medical Equipment
Home Modification/ Environmental Modification
Home Modification/ Environmental Modification
Supervised Residential Care
Supervised Residential Care
Assessment and Re-Assessment
Nursing Supports
Family Training
Physical therapy
Assessment and Re-Assessment
By signing below I, _________________________________________________, certify that this agency is
capable of and agrees to comply with the conditions for participation established in the Acquired Brain Injury
Services regulation (907 KAR 3:090) and/or the Acquired Brain Injury Long Term Care Waiver Services
regulation (907 KAR 3:210). In addition, I certify that all staff shall meet all training requirements prior to the
provision of services.
___________________________________________________________________________________________
Signature of Authorized Representative
________________________________________________________
_____________________________
Title
Date
Please return forms to:
KY Medicaid Provider Enrollment
P.O. Box 2110
Frankfort, KY 40602-2110 9/2010
CLEAR FORM
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