Download Kentucky Map 351 Template
Contents
Steps to Filling Out Kentucky Map 351
Filling out the Kentucky Map 351 form is an important step in applying for Medicaid waiver services. This form collects essential information about the member, their eligibility, and their needs. Follow these steps carefully to ensure all required information is provided accurately.
- Section I – Member Demographics: Fill in the member's name, date of birth, Medicaid Member ID number, and address. Indicate the county code and select the member's sex and marital status. Provide the emergency contact's name and phone number, along with the member's phone number. Indicate whether the member can read and write, and provide their height and weight.
- Section II – Member Waiver Eligibility: Check the type of program applied for and specify the type of application (certification, re-certification, or re-application). Indicate where the member was admitted from and enter the certification period dates. Provide the certification number and confirm whether the member's freedom of choice has been explained. Include the physician's name, license number, phone number, and the member’s primary diagnosis along with any additional diagnoses.
- Section III – Assessment Provider Information: Enter the name, provider number, and phone number of the assessment or reassessment provider. Fill in the provider's street address and city, state, and zip code, along with the contact person's name.
- Section IV – Self Assessment: For SCL, MP, and ABI waivers, answer questions regarding community inclusion, relationships, rights, dignity and respect, health, and lifestyle. Provide detailed responses as needed.
- Section V – Activities of Daily Living: Answer questions about the member's independence in various daily activities such as dressing, grooming, bathing, toileting, eating, ambulation, and transferring. Provide comments and check any applicable assistance needed.
- Section VI – Instrumental Activities of Daily Living: Indicate whether the member can perform tasks like meal preparation, shopping, housekeeping, laundry, medication management, handling finances, and using the telephone. Provide comments and check any applicable assistance needed.
- Section VII – Neuro/Emotional/Behavioral: Answer whether the member exhibits any behavior problems. If yes, provide comments and details about the frequency of these behaviors and any relevant dates for functional analysis or behavior support plans.
Dos and Don'ts
When filling out the Kentucky Map 351 form, it is essential to approach the task with care and attention to detail. Here are some guidelines to consider:
- Do ensure all personal information is accurate, including name, date of birth, and Medicaid Member ID.
- Do check all boxes carefully to indicate the member's eligibility and preferences.
- Do provide clear and concise answers in the assessment sections, especially regarding daily living activities.
- Do confirm that all medical information, including diagnoses and physician details, is current and complete.
- Don't leave any required fields blank; incomplete forms may delay processing.
- Don't use abbreviations or unclear terms that could lead to misunderstandings.
- Don't forget to sign and date the form where indicated, as this verifies the information provided.
- Don't rush through the form; take your time to ensure accuracy and completeness.
Following these guidelines can help ensure that the Kentucky Map 351 form is filled out correctly, facilitating a smoother process for the member's Medicaid waiver assessment.
File Breakdown
| Fact Name | Description |
|---|---|
| Purpose | The MAP 351 form is used to assess eligibility for Medicaid waiver programs in Kentucky, providing necessary information about the member's demographics and health status. |
| Sections | This form includes multiple sections, such as member demographics, waiver eligibility, assessment provider information, self-assessment, and activities of daily living. |
| Governing Law | The MAP 351 form is governed by Kentucky state regulations related to Medicaid services, specifically under KRS Chapter 205 and 907 KAR Chapter 1. |
| Revision Date | The current version of the MAP 351 form was revised in July 2008, indicating that updates or changes may have occurred since then. |
Documents used along the form
When applying for Medicaid waivers in Kentucky, the MAP 351 form is just one piece of the puzzle. To ensure a smooth application process, several other documents may be required. Each of these forms serves a unique purpose and can help clarify the member’s needs and circumstances. Below is a list of essential forms that often accompany the MAP 351.
- MAP 350 Form: This form is crucial for documenting the member's freedom of choice regarding services and supports. It confirms that the member understands their rights and the complaint process.
- Physician's Statement: A letter or form from the member's physician detailing their medical condition and any necessary treatments. This statement supports the need for specific Medicaid services.
- Functional Assessment Form: This form assesses the member's ability to perform daily activities and outlines their needs for assistance. It provides insight into the level of care required.
- Fedex Bill Of Lading Form: This important document details the terms, conditions, and particulars of a shipment, and can be essential for coordinating logistics, such as the Fedex Bill Of Lading form.
- Financial Disclosure Form: This document outlines the member's financial situation. It is essential for determining eligibility for Medicaid services and waivers.
- Consent for Release of Information: This form allows healthcare providers to share the member's medical and personal information with Medicaid services, ensuring that all relevant data is considered in the application process.
- Care Plan: A detailed plan created by the assessment provider, outlining the member's specific needs, goals, and the services they will receive. This plan is vital for coordinating care.
- Emergency Contact Information: A form listing emergency contacts for the member. This ensures that, in case of an emergency, the appropriate individuals can be reached quickly.
Gathering these documents can feel overwhelming, but each one plays a vital role in securing the necessary support for the member. Being thorough and organized will help facilitate the process and ensure that all needs are met promptly.
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FAQ
What is the purpose of the Kentucky Map 351 form?
The Kentucky Map 351 form is designed to assess the eligibility of individuals for Medicaid waiver programs. It collects essential demographic information, medical diagnoses, and details about the member's daily living activities. This information helps determine the level of support required and ensures that individuals receive the appropriate services based on their needs.
Who needs to fill out the Kentucky Map 351 form?
The form must be completed for individuals applying for Medicaid waiver programs, such as the Home and Community Based Waiver or the Acquired Brain Injury Waiver. This includes new applicants as well as those seeking re-certification or re-application. Family members or guardians may assist in completing the form for individuals who are unable to do so themselves.
What information is required in the Kentucky Map 351 form?
The form requires various types of information, including the member's name, date of birth, Medicaid Member ID, and contact details. It also asks for details about the member's medical history, including diagnoses and any assistance needed with daily living activities. Additionally, emergency contact information and assessments of the member’s ability to perform instrumental activities of daily living are required.
How is the information from the Kentucky Map 351 form used?
The information gathered from the Map 351 form is used by the Cabinet for Health and Family Services to evaluate the member's eligibility for Medicaid waiver programs. It helps determine the level of care and support services needed to assist the individual in their daily life. Accurate and complete information is crucial for ensuring that members receive the appropriate resources and assistance.