Kentucky Medicaid Form MAP-14 is the state’s Authorized Representative form. You use it to give one specific person or organization — a relative, friend, attorney, social worker, or provider — permission to apply for Medicaid, report changes, handle renewals, or receive notices on your behalf.1Cabinet for Health and Family Services. Kentucky Medicaid Form MAP 14 The form is one page, takes a few minutes to complete, and stays in effect until you cancel it.
When You Need the Form
Complete MAP-14 any time you want someone else to deal with the Department for Medicaid Services or the Department for Community Based Services for you. Typical situations: a daughter applying for Medicaid for an elderly parent, a social worker enrolling a client, an attorney managing a disabled person’s benefits, or simply wanting another person to receive copies of your Medicaid notices so a deadline doesn’t slip past you.
Federal rules require every state Medicaid agency to let applicants and beneficiaries name an authorized representative, either when they apply or any time after.2eCFR. 42 CFR 435.923 – Authorized Representatives MAP-14 is how Kentucky documents that choice. You don’t need it if you plan to handle your case yourself, and you can add a representative later if things change.
How to Fill Out MAP-14
Download the PDF from the Cabinet for Health and Family Services member resources page, print it, and complete it by hand.3Cabinet for Health and Family Services. Resources and Forms At the top, print your name (the applicant or member) and the name of the person you’re authorizing. Then check one of three boxes defining what that person can do (covered in the next section).
Below the checkboxes, you and your representative each fill in a column with the same categories of information:1Cabinet for Health and Family Services. Kentucky Medicaid Form MAP 14
- Printed full legal name
- Signature — if you can’t write and sign with an “X,” a witness also has to sign
- Mailing address, city, state, and zip
- Phone number
- Date signed (the authorization takes effect on the date you sign)
- Email address (optional)
- Your representative also fills in their relationship to you or the name of their company — for example, “daughter,” “attorney,” or an agency name
You don’t need a Medicaid case number, Social Security number, or provider ID on the form itself. By signing, your representative agrees to give the state truthful, complete information and to keep what the agency shares about you confidential. Knowingly providing false information or hiding relevant facts can lead to prosecution.
Picking the Right Authority Level
The three checkboxes on MAP-14 are nested — each option includes everything above it:1Cabinet for Health and Family Services. Kentucky Medicaid Form MAP 14
- Apply and report changes. Your representative can submit the initial application and tell the state about changes like a new address, income shift, or household change.
- Apply, report changes, and recertify. Adds the authority to complete your annual Medicaid renewal. This is the practical pick for anyone helping a family member keep coverage year after year.
- Apply, report changes, recertify, and receive notices. The broadest option. Your representative gets copies of every letter the state sends about your case, including approvals, denials, and renewal reminders.
If the point of naming a representative is to help someone who struggles with paperwork, the third option usually makes the most sense. A representative who never sees the notices can’t respond to deadlines they don’t know about.
Where to Send the Completed Form
Once both of you have signed, submit the form through any of these channels:
- Mail: Department for Medicaid Services, 275 E. Main St., 6E-D, Frankfort, KY 40621.
- Fax: (502) 564-3852.
- In person: Your local DCBS office. Staff there can also help you fill it out.
- Upload to kynect: If you have a kynect benefits account, scan or photograph the signed form and upload it through the Document Center on your dashboard.
For kynect uploads, image files have a 6 MB limit and document files a 4 MB limit. Accepted formats are PDF, TIF, TIFF, JPEG, JPG, and PNG. Make sure the image is clear and captures the whole page.4Cabinet for Health and Family Services. Quick Reference Guide Document Upload
Adding a Representative Online Instead
If you already use kynect benefits, you can skip the paper form entirely. Log in and go to the Get Local Help screen, reachable from the top menu, the “Reps, kynectors, & Agents” tile on your dashboard, or from inside the benefits application.5Cabinet for Health and Family Services. Quick Reference Guide Add, Edit, and Remove an Authorized Representative
Click “Add an Authorized Representative” and enter the person’s first name, last name, and email address. The system searches for them. If they aren’t already registered, you’ll be prompted for their Social Security number, date of birth, gender, phone number, and preferred language. You’ll also choose how they’re related to you and provide their mailing address. On the final screen you pick which programs they can access, read the terms, and electronically sign by typing your name. The typed signature has to match the name on your kynect account or the submission won’t go through.
The online path creates an immediate record and is useful if you’re mid-application and want your representative added right away.
If You Already Have Power of Attorney or Guardianship
You don’t necessarily need MAP-14 if someone already holds legal authority over your affairs. Under federal Medicaid rules, a power of attorney or a court order of legal guardianship counts as a written designation of authorized representation.2eCFR. 42 CFR 435.923 – Authorized Representatives The state may ask for a copy of the legal document to verify the authority, but a separate MAP-14 isn’t required on top of it.
MAP-14 is simpler than drafting a power of attorney, which typically needs notarization and covers much broader legal and financial decisions. If Medicaid is the only thing you need help with, MAP-14 handles it without that extra expense.
Changing or Canceling Your Representative
There’s no automatic expiration. The authorization runs until you end it. To remove a representative, notify the Department for Medicaid Services that the person is no longer authorized. The representative can also contact the agency to step down.2eCFR. 42 CFR 435.923 – Authorized Representatives
If you set the representative up through kynect, you can edit or remove them from the Get Local Help screen without any paper.5Cabinet for Health and Family Services. Quick Reference Guide Add, Edit, and Remove an Authorized Representative To switch to a different person, remove the current representative and add the new one, or submit a new MAP-14 naming the replacement — the new form effectively supersedes the old one.