Welcome!
This application is for those who already have MEDICAID and are interested in the Medicaid Waiver Program!
If you have questions regarding this, please contact us at 270-689-0005. We are here to help!
If you wish to continue please start now.
Caller Name (Name & Number)
OPTIONAL. Only answer if you are calling on behalf of someone else.
How did you hear about us?*
Client Name*
Person needing services (first and last name)
Gender*
Client Phone Number *
If the client does not communicate please provide the number to call back.
Client Street Address*
City*
Zip Code*
Social Security Number*
Date of Birth*
Emergency Contact or “Other” Contact
Family Doctor or Provider Name and Phone Number *
Family Dr. or Provider FAX number
Medicaid Number*
10 Digit Medicaid ID (this will not have any letters ONLY numbers)
Please explain why you or the participant will be needing this program?
Example- Physical/Mental dependencies, disabilities, etc…
