1915(c) HCBS Waiver Flooding 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 flooding in eastern Kentucky 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) participants.

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. 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/9u1i52ZirpWnvHf96.
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I am filling this form out: 
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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.
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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?
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Is the place where you live damaged?
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If the place where you live is damaged, are you able to stay there?
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If you are unable to stay in the place where you live, do you have a safe place to stay for now?
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Do you have electricity where you are staying right now?
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Do you have all the supplies or medications you need right now?
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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 flooding? 
How can DMS help you at this time?
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