DHS-1344-G Guardianship Assistance Case Opening Request



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MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

(Revised 7-21)

|INSTRUCTIONS |

|The foster care worker completes the entire form. The guardian and the worker sign on page 2. Incomplete forms will be returned to the foster care worker. Payments |

|cannot begin without all required information. |

Section 1 – child information

|CHILD’S NAME (LAST, FIRST, MIDDLE) |Child’s Person ID |

|       |      |

|Child’s Birthdate |Child’s Social Security Number |Child’s Race |Child’s Sex |

|      |      |      |      |

section 2 – guardian parent information

PAYMENTS CAN ONLY BE ISSUED IN ONE GUARDIAN’S NAME.

|Guardian Parent Name |Guardian Parent Name, if more than one |

|(Last, First, Middle) |(Last, First, Middle) |

|       |      |

|Guardian Parent Birthdate (mm/dd/yyyy) |Guardian Parent Birthdate (mm/dd/yyyy) |

|      |      |

|Social Security Number of Above Guardian |Social Security Number of Above Guardian |

|      |      |

|Guardian Parent Email Address |Guardian Parent Email Address |

|      |      |

|Home Address (Number and Street) |City |State |Zip Code |

|      |      |      |      |

|Mailing Address (if different from above, or PO Box) |City |State |Zip Code |

|      |      |      |      |

|Home Phone Number |Work Phone Number |Whose Number? (Name) |

|      |      |      |

section 3

|SIGMA VENDOR NUMBER |MiSACWIS Provider ID |

|       |      |

|Indicate Primary Provider in MiSACWIS |Indicate Guardian Assistance/Medical Subsidy Payee |

|      |      |

section 4

|1. |TYPE OF ASSISTANCE |Guardian Order Date |

| |  Guardian Assistance Medical Subsidy |(JC 91) |

| |Nonrecurring Adoption Expenses |      |

|2. |Criminal History |

| |Does any adult (age 18 or over) in the household have felony convictions for any of the following: |

| |Child abuse or neglect, spousal abuse |

| |Crime against children, including pornography |

| |Violence, rape, sexual assault, homicide |

| |Within the last five years: physical assault, battery, or a drug related offense |

| |  Yes No |If yes, name and relationship |      |

|3. |Medical Coverage for Child (Other than Medical Subsidy) |

| | Medicaid Children’s Special Health Care Services |

| |Insurance No insurance coverage for child |

|Insurance Company Name #1 |Insurance Policy Number |

|      |      |

|Coverage/Policy Type |

|Major Medical Dental Vision Catastrophic Only |

|Insurance Company Name #2 |Insurance Policy Number |

|      |      |

|Coverage/Policy Type |

|Major Medical Dental Vision Catastrophic Only |

|Insurance Company Name #3 |Insurance Policy Number |

|      |      |

|Coverage/Policy Type |

|Major Medical Dental Vision Catastrophic Only |

| |

section 5 – signatures

|TO THE BEST OF MY KNOWLEDGE, THE FOLLOWING INFORMATION IS ACCURATE AND COMPLETE. |

|Guardian(s) Signature | |Date |

|Foster Care Worker Signature | |Date |

|Telephone Number |Agency Name |

|       |      |

section 6 – instructions

(DO NOT TYPE BEYOND THIS POINT)

|Assure that all necessary information has been entered and scanned into MiSACWIS. Attach a copy of: |

|The guardianship assistance agreement with the MDHHS Adoption and Guardianship Assistance Office program manager signature. |

|The medical subsidy agreement with the MDHHS Adoption and Guardianship Assistance Office program manager signature, if the child is eligible for medical subsidy. |

|The JC 91, Order Appointing Juvenile Guardian. The final signed guardianship assistance agreement, if eligible for guardianship assistance. |

|Retain a copy for your records. |

|The foster care worker must email the Adoption and Guardianship Assistance Office at |

|MDHHS-AGAO-apps-and-openings@ to notify the office that case opening documents have been uploaded. |

|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, gender identification or expression, sexual orientation, partisan considerations, |

|or a disability or genetic information that is unrelated to the person’s eligibility. |

|AUTHORITY: Act 280 of 2008, as amended. COMPLETION: Mandatory |

|PENALTY: Failure to comply may result in inability to open case. |

End of form

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