Adoption Assistance Program Change Request
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MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
(Revised 11-21)
|Child has been certified eligible for Adoption Assistance Adoption Medical Subsidy |
|Has the PCA 320, Order Placing Child, been signed? Yes No |
|Has the PCA 321, Order of Adoption, been signed? Yes No |
|Child’s circumstances have changed as indicated below. |
|Required documents per adoption assistance policy are attached for review by the Adoption and Guardianship Assistance Office and issuance of a new agreement(s) if |
|applicable. |
section 1 – identifying information
|CHILD’S NAME (LAST, FIRST, MIDDLE) |
| |
|Date of Birth |Date of Order Placing Child, if applicable |Child Person ID |
| | | |
|Adoption Worker Signature |Adoption Worker – Printed Name |
| | |
|Agency Name |
| |
|Agency Address |City |State |Zip Code |
| | | | |
|Phone Number |Email Address |Date |
| | | |
section 2 – rate/funding/eligibility change
| CHILD’S FOSTER CARE DETERMINATION OF CARE (DOC) RATE HAS CHANGED. |
| New DOC (DHS-470, DHS-470A, DHS-1254, or DHS-1945). |
| Supporting documentation for the current DOC, including exception requests for DOCs above Level 3. |
| New DHS-668, Notification of Determination of Care Decision. |
| Current USP/PWSP and PATP. |
| New DHS-959, Adoption Assistance Rate Determination Worksheet |
| Child’s foster care funding source eligibility has changed. Review the adoption assistance funding source. |
| Child is now eligible for or receiving SSI in the amount of $ /month. |
|Payee: |
| The adoptive parents have incurred a criminal conviction following order placing child but prior to order of adoption. |
| The child has had a birthday that effects eligibility or rate determination. |
section 3 – adoption plan change
| THERE HAS BEEN A CHANGE IN THE CHILD’S PERMANENCY PLAN. THE CHILD’S PLAN IS NO LONGER ADOPTION. |
| THERE HAS BEEN A CHANGE IN THE CHILD’S ADOPTION DUE TO A DIVORCE, OR DEATH OF ONE PARENT IDENTIFIED TO ADOPT THE CHILD. THE FOLLOWING DOCUMENTATION IS ATTACHED: |
| NEW DHS-4081, ADOPTION ASSISTANCE INTENT STATEMENT. |
| NEW DHS-959, ADOPTION ASSISTANCE RATE DETERMINATION WORKSHEET. |
| ADDITIONAL EXPLANATION, AS APPROPRIATE. NOTE: A NEW DHS-1341 IS NOT REQUIRED. |
| NAME OF PROSPECTIVE ADOPTIVE PARENT CONTINUING WITH PLAN TO ADOPT: |
| THERE HAS BEEN A CHANGE IN THE CHILD’S ADOPTION PLAN: |
| A NEW FAMILY HAS BEEN IDENTIFIED TO ADOPT THE CHILD. A NEW DHS-1341 WITH REQUIRED DOCUMENTATION FOR ADOPTION ASSISTANCE IS ATTACHED. |
| A NEW FAMILY HAS BEEN IDENTIFIED TO ADOPT THE CHILD WHO HAS AN APPROVED MEDICAL SUBSIDY AGREEMENT. |
| THE PROSPECTIVE ADOPTIVE PARENT HAS MARRIED AND THE SPOUSE IS ALSO ADOPTING. A NEW DHS-1341 WITH REQUIRED DOCUMENTATION IS ATTACHED. |
| THE PREVIOUS IDENTIFIED FAMILY IS NO LONGER ADOPTING. |
| OTHER |
| A NEW NEGOTIATED RATE IS BEING REQUESTED. A NEW DHS-959 WITH REQUIRED DOCUMENTATION IS ATTACHED. |
| THE AGENCY RESPONSIBLE FOR THE CHILD’S ADOPTION PLANNING HAS CHANGED. |
|New agency assigned: |
| An adoption disruption has occurred on . |
|Description of situation: |
section 4 – health status change – medical subsidy request
| THE CHILD HAS ADDITIONAL DIAGNOSED PHYSICAL, MENTAL, OR EMOTIONAL CONDITIONS. APPROPRIATE PROFESSIONAL DOCUMENTATION IS ATTACHED FOR THE FOLLOWING CONDITIONS: |
| |
section 5 – other change
| OTHER, SPECIFY: |
(DO NOT TYPE BEYOND THIS POINT)
|The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because |
|of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated |
|to the person’s eligibility. |
|AUTHORITY: 1939 PA 280 COMPLETION: Voluntary. PENALTY: Delay of subsidy determination. |
End of form
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