Aged & Disabled Waiver Medical Eligibility Request

Description:

The first step in applying for the Aged & Disabled Medicaid Waiver program is completion of the Medical Necessity Evaluation request. The top portion of the form is to be completed by the applicant or the applicant's representative. If the applicant has Alzheimer's Disease or other dementia, a contact person must be listed on the request and must also attend the evaluation. The applicant or representative must sign the request for evaluation. The second portion of the form should be completed by the applicant's primary care physician. The referring physician must sign and date the request. The completed request should be mailed or faxed to WVMI. WVMI's contact information is listed on the top of the request. The request must be received by WVMI within 60 days of the date of the doctor's signature. Upon receipt, a Registered Nurse from WVMI will contact the applicant or representative to schedule an evaluation date. The applicant will be given a minimum of two weeks notice when scheduling the evaluation date. Website: http://www.dhhr.wv.gov/bms/Programs/WaiverPrograms/ADWProgram/Pages/ADW-Policy-and-Forms.aspx

Address Listings

Town:

Charleston

Phone Numbers

Miscellaneous