Medicaid Flooding Assistance Form - Home Health or Private Duty Nursing MEMBERS

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The Kentucky Department for Medicaid Services (DMS) is working to determine the needs of Medicaid members affected by flooding in eastern Kentucky July 27-28, 2022. Your responses will give DMS the information it needs to provide relief to members affected by this devastating event.

If you have been affected by the flooding but are unable to complete this survey online, please contact the 1915(c) Waiver Help Desk at (844) 784-5617 and choose option 6. A DMS staff member will ask you the questions and take down your answers over the phone.

If you are a Nursing Facility, Home Health, or Private Duty Nursing PROVIDER, please complete the provider form at https://forms.gle/EfsXz9zhVBUgFx1e8.

I am filling this form out:

For myself.

As a provider or case manager on behalf of a member.

A DMS staff member on behalf of a member.

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Your Name

Name of Member Affected (if completing on a member's behalf)

Please select the service in which the member is enrolled.

Home Health

Private Duty Nursing

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Last Four Digits of Medicaid ID Number of Affected Member (if Available)

County Where Member Lives

Please let us know the best way to contact you at this time.

Were you injured in the flooding?

Yes, I have minor injuries.

Yes, I have serious injuries.

No, I am not injured.

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Is the place where you live damaged?

Yes

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If the place where you live is damaged, are you able to stay there?

Yes

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If you are unable to stay in the place where you live, do you have a safe place to stay for now?

Yes

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Do you have electricity where you are staying right now?

Yes

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Do you have all the supplies or medications you need right now?

Yes

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If you do not have the supplies or medications you need, please tell us what you need.

Do you have any needs other than supplies or shelter that are not being met right now because of the flooding?

How can DMS help you at this time?

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