MAP 14 Commonwealth of Kentucky

(10/21) Cabinet for Health and Family Services

Department for Medicaid Services
AUTHORIZED REPRESENTATIVE

I ARINA ALIC have asked LUKE BOND/ELEVATEPFS

(Print Your Name) (Print Authorized Representative’s Name)
to help me as I have chosen below with Medicaid. This authorization is valid from the date of applicant’s signature until the
form is rescinded by the applicant.

I give my permission for the person named above as my authorized representative to (please check all that apply):
Elevate patient advocates include but are not limited to: Nicole Heim, Yesenia
RosalesAvila, Kendall Fisk, Tasha Smith, Damon Goins, Whitney Hurst, Luke Bond,
Eric Tillman, Jasmine Nelson, Courtney Freeman, LaShawnda Johnson, DeShari
Apply, Report Changes Mack, Elia Rodriguez, Brandy Felton, Brittany Kapfhammer, Brittany Shields, Tee
McClain, Kim Travis, Lexi Sapp, Melissa Kapfhammer, Kathy Black, Sierra Cox, Gloria
Apply, Report Changes, Recertify
Ledbetter, Crystal Peach, Angela Willey, Yvonne Arroyo and Doris Whitacre.
Apply, Report Changes, Recertify and receive a copy of Notices

I understand that I or my authorized representative, must provide complete and truthful information to have my
Medicaid eligibility determined or redetermined. My authorized representative is responsible for fulfilling all
responsibilities designated above as well as agreeing to maintain the confidentiality of any information regarding
the applicant or member provided by the agency.

If I or my authorized representative knowingly provides false information or withholds information, I may

be subject to prosecution for fraud.

Eligibility determinations may take up to 30 days from the date of application to be completed. All identification
cards and letters will be mailed to the address you choose. You will need to show your identification card to your
medical providers so they can bill Medicaid for the services you received.

ARINA ALIC LUKE BOND/ELEVATEPFS

Printed Applicant/Member Name Printed Authorized Representative Name

Applicant/Member Signature Authorized Representative Signature

1007 FENLEY AVE 530 S Jackson Street

Applicant/Member Address Authorized Representative Address

LOUISVILLE, KY 40222 Louisville, KY 40202

City, State, Zip City, State, Zip

502-295-7863 502-861-7453
Phone Number Phone Number

July 19, 2023 July 19, 2023

Date Signed Date Signed

Lucas.Bond@elevatepfs.com
Witness (if signed by X) Email Address

Authorized Rep - Elevate

Relationship or Company Name