Medicaid Flooding Assistance Form - FAMILY MEMBERS of Nursing Facility Resident

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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:

A DMS staff member on behalf of a member's family.

As a family member trying to locate a nursing facility resident.

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Your Name

Name of Member Affected (if completing on a member's behalf or searching for member in a nursing facility)

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

Name of Nursing Facility Where Member Resides

County Where Nursing Facility Located Prior to Flooding

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

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