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 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) providers.

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 PARTICIPANT, please complete the participant form at https://forms.gle/dAmqk4n1yfoXKL2j6.
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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
Services your agency provides (Check all that apply)
Please let us know the status of you and your staff members to the best of your knowledge.
Clear selection
Have you been able to check on the participants your serve?
Clear selection
If you have been able to check on your participants, please let us know their status.
Did the building(s) where you provided services or conduct business sustain damage?
Clear selection
If your building(s) sustained damage, how would you classify it?
Clear selection
Are you able to provide waiver services at this time?  
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.
Clear selection
Please tell us if there are any other barriers you have to providing services due to the severe weather outbreak.
What can DMS do to help you at this time?
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