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Southwest Mississippi Planning & Development District
SOUTHWEST MISSISSIPPI PLANNING & DEVELOPMENT DISTRICT
100 South Wall Street
Natchez, MS 39120
Phone (601) 446-6044
Fax (601) 446-6071


ELDERLY AND DISABLED MEDICAID WAIVER PROGRAM

APPLICATION TO RECEIVE SERVICES FROM THE ELDERLY & DISABLED MEDICAID WAIVER PROGRAM

  • Please complete and submit this form if you are interested in receiving services provided by the Elderly and Disabled Medicaid Waiver Program.
  • Qualifying individuals can complete and submit this form themself, or, a referrer can complete and submit this form on behalf of a qualifying individual to receive services provided by the Elderly and Disabled Medicaid Waiver Program.
  • Information requested is for the qualifying individual.
  • Fields marked with a red asterisk (*) are required.
  • Please provide as much information as possible.
  • After you submit this application, your name will be placed in a waiting list in the order received, and you will be contacted when resources become available to serve more individuals.
Social Security Number: *
First Name: *
Middle Initial:
Last Name: *
Date of Birth: * (mm/dd/yyyy)
Address Line 1: *
Address Line 2:
City: *
State: MS
Zip: *
Phone: *
County: *
Email Address:
Gender: *
Currently Living at: *
If "Other", please describe:
Medicaid #:
Medicare #:
Service(s) Needed:


Contact Person's Name: *
Contact's Relationship to Applicant: *
Contact's Phone #: *
Directions to Home:
Referrer:
Referrer's Phone #:
Physician's Name:
Physician's Phone #:
Physician's Address:
Physician's City:
Physician's Zip:
Diagnosis:
Type the code shown above: *  



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