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Resource pages currently cover Kentucky and Indiana.

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This directory is under active review and may be incomplete. Confirm urgent details directly; No One Left Outside does not guarantee eligibility, availability, funding, acceptance, or placement.

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Kentucky Waiver Services Physician's Recommendation

Official owner Kentucky Cabinet for Health and Family Services

Clinical recommendation supplied by an eligible practitioner for waiver processes that require MAP-10.

What problem this helps solve

Clinical recommendation supplied by an eligible practitioner for waiver processes that require MAP-10.

Who completes it: Authorized practitioner for the selected waiver; applicant/helper arranges the request.

What this does not prove

Official instructions and the person's notice control; an application is not an eligibility or approval decision.

Dated source check

Official destination opened — currentness caution

Current January2026 guide references MAP-10 for specified waivers. Linked one-page form itself saysRev 06/15; verify any program-specific practitioner requirements.

Last checked Sep 30, 2026. A working link does not establish the current edition, suitability, agency acceptance, or service availability.

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Use the official pathway

NOLO's preparation notes summarize the dated sources in this record. Follow the agency's official instructions and current edition when they differ.

1. Check that this route fits

Stage and purpose
Clinical evidence before waiver review
Who completes it
Authorized practitioner for the selected waiver; applicant/helper arranges the request.
Jurisdiction
Kentucky
Application mode
Practitioner-completed paper support

2. Prepare before starting

  • Determine whether selected waiver requires MAP-10 and which practitioner may complete it.

Documents named by the source

  • Patient diagnoses and waiver recommendation; other clinical reports vary by waiver.
Fees and fee waivers
UNKNOWN — practitioner appointment/document charges not verified.
Account
No account requirement stated on this form.
Appointment
A practitioner review may be necessary; availability UNKNOWN.
Signature
Practitioner signs and dates recommendation and provides identifying/NPI information.
Third-party certification or assessment
Eligible practitioner recommendation and signature required.

3. Follow official submission instructions

Read official instructions
  • Return to the requestor identified on the form; include in agency-directed waiver evidence

4. Get help or an accommodation

Languages: English source read; other versions UNKNOWN.

Accessibility: External source conformance was not evaluated; request agency assistance for an inaccessible process.

5. Know the supported next step

  • Return signed recommendation to named requestor and keep a copy.

Restrictions and unresolved details

  • Old printed edition is currently linked; follow current waiver guide and agency acceptance instructions.
  • The form alone is not a waiver application or approval.

Official instructions and the person's notice control; an application is not an eligibility or approval decision.

PDF filling support

PDF with fillable fields. Checked 2026-10-05. Signature support and agency acceptance still need confirmation.

Continue with your journey

Return to the connected step to decide what to do next. Opening this record does not complete that step or submit an application. If the official route is unavailable, use the assistance options above or browse help in the journey.

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Form record

Adds to a private plan in this browser tab. Nothing is sent to the provider, and nothing is applied for.

Official title
Kentucky Waiver Services Physician's Recommendation
Form number
MAP-10
Program
HCBS waiver clinical support
Jurisdiction
Kentucky
Revision / edition
Jun 2015
Who completes it
Authorized practitioner for the selected waiver; applicant/helper arranges the request.
Signature
Practitioner signs and dates recommendation and provides identifying/NPI information.
Submission methods
Return to the requestor identified on the form; include in agency-directed waiver evidence
Supporting documents
  • • Patient diagnoses and waiver recommendation; other clinical reports vary by waiver.
Languages
English source read; other versions UNKNOWN.
Accessibility
External source conformance was not evaluated; request agency assistance for an inaccessible process.

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Source note: Official instructions and the person's notice control; an application is not an eligibility or approval decision.

NOLO does not process this form, receive your answers, decide eligibility, or represent the agency. A destination check does not confirm current funding, acceptance, or an outcome.

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