1915(c) HCBS Waiver Storm Assistance Form

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1915(c) HCBS Waiver Storm Assistance Form - PROVIDERS

The Kentucky Department for Medicaid Services (DMS) is working to determine the needs of 1915(c) Home and Community Based Services (HCBS) waiver providers affected by flooding in eastern Kentucky on July 27-28, 2022. 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) providers.

If you have been affected by flooding 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 PARTICIPANT, please complete the participant form at https://forms.gle/PwBoLUfeBnMcamT9A.

I am filling this form out:

As a provider or case manager on behalf of my agency.

As a DMS/DAIL/DDID staff member on behalf of a provider.

Clear selection

Provider Agency Name

Provider Number (If available)

Provider County

Provider Address

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

Types of Participants Your Agency Supports

Traditional Only

PDS Only

Blended (You support traditional and PDS participants).

Services your agency provides (Check all that apply)

Case Management

Community Services

In-Home Services

Residential

Respite

Services Delivered by a Licensed Professional

Services in Congregate Settings

Please let us know the status of you and your staff members to the best of your knowledge.

All of our staff members are safe and accounted for.

We have staff members who are unaccounted for.

We have staff members who have been injured.

We have staff members who have died.

Other:

Clear selection

Have you been able to check on the participants your serve?

Yes

Clear selection

If you have been able to check on your participants, please let us know their status.

All of our participants are safe and accounted for.

We have participants who are unaccounted for.

We have participants who have been injured.

We have participants who have died.

Did the building(s) where you provided services or conduct business sustain damage?

Yes

Clear selection

If your building(s) sustained damage, how would you classify it?

Minor

Moderate

Major

Building is a total loss.

Clear selection

Are you able to provide waiver services at this time?

Yes

Clear selection

Do you have all the supplies you need to provide waiver services? In particular, those needed to meet a participant's immediate health needs such as oxygen, supplies for tube feedings, medications, etc.

Yes

Not sure

Clear selection

Please tell us if there are any other barriers you have to providing services due to flooding.

What can DMS do to help you at this time?

Submit

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