1915(c) HCBS Waiver Storm Assistance Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

1915(c) HCBS Waiver Storm Assistance Form - PARTICIPANTS

The Kentucky Department for Medicaid Services (DMS) is working to determine the needs of 1915(c) Home and Community Based Services (HCBS) waiver participants affected by storms and tornadoes in western Kentucky on December 10-11, 2021. Your responses will give DMS the information it needs to provide relief to HCBS providers and participants affected by this devastating event. This survey applies to both traditional and participant-directed services (PDS) participants.

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

If you are a PROVIDER AGENCY, please complete the provider form at https://forms.gle/K6pXjjyhWkboLNGo6.

Your Name

Name of Waiver Participant Affected (if completing on a waiver participant's behalf)

Please select the waiver in which the participant is enrolled.

Acquired Brain Injury or Acquired Brain Injury Long Term Care

Home and Community Based

Model II Waiver

Michelle P. Waiver

Supports for Community Living

Clear selection

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

County Where Participant Lives

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

Were you injured in the storm?

Yes, I have minor injuries.

Yes, I have serious injuries.

No, I am not injured.

Clear selection

Is the place where you live damaged?

Yes

Clear selection

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

Yes

Clear selection

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

Yes

Clear selection

Do you have electricity where you are staying right now?

Yes

Clear selection

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

Yes

Clear selection

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 severe weather?

How can DMS help you at this time?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms