Kentucky Medicaid requires the MAP-10 as part of eligibility for its 1915(c) waiver programs. The physician, APRN or PA lists the member's diagnoses, marks the recommended waiver and certifies that without waiver services, placement in a nursing facility or ICF for individuals with an intellectual disability would be appropriate. The signed form goes back to the agency that requested it.
The requesting agency fills in its name and contact details at the top. The physician, APRN, PA or SCL IDP enters the member's details and diagnoses, checks the waiver program and signs with NPI and date.
Download the current version from the source each time; forms change without notice.
Waiver Services Physician's Recommendations
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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For some waivers. An APRN or PA may sign for the Home and Community Based waiver and the Michelle P. waiver. The ABI and ABI Long Term Care waivers require a physician's signature, and the SCL waiver requires a physician or an SCL IDP.
The signer recommends waiver services for the member and certifies that if waiver services were not available, institutional placement in a nursing facility or an intermediate care facility for individuals with an intellectual disability would be appropriate. This links the waiver to institutional level of care.