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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