Medicaid Storm Assistance Form - Nursing Facilities, Home Health and Private Duty Nursing PROVIDERS

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The Kentucky Department for Medicaid Services (DMS) is working to determine the needs Medicaid members and 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 Medicaid providers and participants affected by this devastating event.

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 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 member who receives Home Health or Private Duty Nursing and have been affected by flooding, please complete the member form at https://forms.gle/DQYVBAxPeBWT5nxQ7.

If you are a family member trying to locate a Nursing Facility resident, please complete the form at https://forms.gle/TekXQewjB9MnjGjn8.

I am filling this form out:

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

As a DMS 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.

Services your agency provides (Check all that apply)

Nursing Facility

Home Health

Private Duty Nursing

Other:

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

Home Health and PDN agencies: Have you been able to check on the members your serve?

Yes

Clear selection

Home Health and PDN: If you have been able to check on your members, 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 services at this time?

Yes

Clear selection

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

Yes

Not sure

Clear selection

Nursing Facilities: Have you had to evacuate members due to flooding and/or flood damage?

Yes - If yes, please contact the 1915(c) Waiver Help Desk at 1915cWaiverHelpDesk@ky.gov or (844) 784-5614 so DMS can facilitate payment.

Clear selection

Nursing Facilities: Have you been able to contact family members of all residents to let them know where their loved one has been moved?

Yes

No, but we do not need assistance with this task.

No and we need assistance with this task.

Clear selection

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

What else can DMS do to help you at this time?

Submit

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