WV I/DD WAIVER APPLICATION

WEST VIRGINIA I/DD WAIVER APPLICATION
*Applicant must be at least 3 years of age and a WV resident on the date of submission*
Applicant Information*
First Name, MI, Last Name

First NameMiddle InitialLast Name
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Mailing Address - Street Address
City
State
Zip Code
Address
Phone Number
Format: (000) 000-0000.
Social Security Number
Medicaid Number, If The Applicant Has One
Gender
Applicant Email Address, If The Applicant Has One
example@example.com
County of Residence
Legal Representative Information
Legal Representative Type
Legal Representative First Name, MI, Last Name

First NameMiddle InitialLast Name
Name 2
Legal Representative Phone Number
Format: (000) 000-0000.
Legal Representative Mailing Address - Street Address
City
State
Zip Code
LR Mailing Address
Legal Representative Email Address
example@example.com
Non-Legal Representative Information (if applicable)
Non-Legal Representative First Name, MI, Last Name

First NameMiddle InitialLast Name
NLR Name
Non-Legal Representative Relationship to Applicant
Non- Legal Representative Mailing Address - Street Address
City
State
Zip Code
NLR Mailing Address
Non-Legal Representative Phone Number
Format: (000) 000-0000.
Non-Legal Representative Email Address
example@example.com
Applicant/Legal Representative Signature
**Proof of residency must be included with this application including a photo ID or utility bill showing the WV physical address in the name of the applicant (or legal representative if applicable).

**For applicants aged 18 and older who have a legal guardian, proof of guardianship must be submitted with this application.
Printed Name of Applicant or Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Applicant or Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Form Submission
You can submit this applicaton directly to Acentra as follows:

After you complete the from, select "Preview PDF" to download, save, or print your form.

• Email: wviddwaiver@acentra.com

• Fax#: (866)521-6882

• Mail: Acentra Health - 1007 Bullitt Street, Suite 200 Charleston, WW 25301

If you have not heard back from Acentra Health within 5 business days, please call toll free 866-385-8920.

If you prefer, CSI can submit this application for you.

If so, click on the "Submit to CSI" button and send us a copy of your proof of residency and guardianship documents, if applicable.

E-Mail: billing@csiwv.com

Fax: 304-205-7984
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WEST VIRGINIA I/DD WAIVER APPLICATION

Applicant Information*

Legal Representative Information

Non-Legal Representative Information (if applicable)

Applicant/Legal Representative Signature

Form Submission