Kentucky K-TAP parents can be exempt from Kentucky Works activities, or get an extension past the K-TAP time limit, when they must care for a disabled spouse, child or parent at home with no alternative care. The PA-4 is how DCBS verifies that need: the disabled person's health care provider states who needs care, how many days a week, and for how long.
The health care provider of the person who needs care completes and signs the whole form. The K-TAP parent receives it from DCBS and brings it to that provider.
Download the current version from the source each time; forms change without notice.
Statement of Required Caretaker Services
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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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From the patient's family. DCBS does not post it as a public download; it is printed locally or system-generated and sent to the K-TAP applicant with a Request for Information. The family brings it to the health care provider of the person who needs care.
At least every six months, or sooner when the care end date on the form expires. For time-limit extensions, the extension is reviewed and a new PA-4 completed at least every six months. If a renewal requested by DCBS is not returned by the end of the month, the exemption ends.