All Program Eligibility Narrative Version 1 –Revised 7/30/06



TRACS Template Library

Table of Contents

All Program Eligibility Narrative Version 1** Page 4

All Program Eligibility Narrative Version 2** Page 11

All Program Eligibility Narrative Version 3 Page 15

All Program Eligibility Narrative Version 4** Page 17

ERDC Only Program Eligibility Narrative** Page 21

CCB Information to DPU Page 23

Domestic Violence Assistance Agreement – TRACS Supplement Page 24

TA-DVS Eligibility and Assessment Addendum (Optional) Page 25

Interim Change Report Narrative Version 1** Page 29

Interim Change Report (852) Template Version 2** Page 31

Interim Change Report Narrative Template Version 3** Page 32

FS Only Eligibility Narrative** Page 34

Combined ERDC and FS Narrative** Page 37

BED Date Added – Benefits Restored Page 40

Date of Request by Phone/Office Contact Page 41

OHP Approval Combined with OPU No Program Available Denial Page 42

Approved Medical Application Page 44

No Medical Program Available Denial Page 46

Duplicate/Concurrent Denial Page 47

Denied or Closed OHP Only Application Page 48

EXT Eligibility Determination Page 50

EXT Medical Quarterly Income Report Narrative Version 1 Page 51

EXT Medical Quarterly Income Report Narrative Version 2 Page 52

Medical Eligibility Template** Page 54

TRACS OHP Intake Form Page 56

Medical Application/Reapplication Narrative Template** Page 58

Office of Central Support (5503) Templates

5503 has a variety of special projects and project teams and processes reports for all SSP branch offices (and some SPD branches!). Included are templates for the phone bank, Children’s Medical Project Team, Breast and Cervical Cancer Program, Senior Prescription Drug Program, Address Project, Pregnancy/pregnancy loss and termination, Newborn Notifications and CHP report processing.

5503 Children’s Medical Project – Facility Placement Page 60

5503 Children’s Medical Project – Status Change/Closure Page 61

5503 Children’s Medical Project – DD/MFC Page 62

5503 Children’s medical Project – Eligibility Review Page 63

5503 Children’s Medical Project – SREL/SAC Page 64

5503 Children’s Medical Project – SREL Eligibility Review Page 65

OHP – 5503 BCCP Approved – Pend Citizen/Identity Page 66

OHP – 5503 BCCP Approved – Pend Citizen/Identity (version 2) Page 67

OHP – 5503 BCCP New/Approved Page 68

OHP – 5503 BCCP Close at Redetermination Page 69

OHP – 5503 BCCP Redetermination Approved Page 70

OHP – 5503 BCCP Redetermination Page 71

OHP - 5503 Senior Prescription Drug Program – Approved Page 72

OHP – 5503 Senior Prescription Drug Program – Approve/Pend for

Program Fee Page 73

OHP – 5503 Senior Prescription Drug Program – Closure Page 74

OHP – 5503 Senior Prescription Drug Program – Closure (version 2) Page 75

OHP – 5503 Senior Prescription Drug Program – Denial Page 76

OHP – 5503 Senior Prescription Drug Program – Pend Page 77

OHP – 5503 BED Date Added – Benefits Restored Page 78

OHP – 5503 Bypass End Date App Created Page 79

OHP – 5503 Bypass End Date Reapp Received Page 80

OHP – 5503 Bypass End Date Phone Contact Page 81

OHP – 5503 Pregnancy Notification Page 82

OHP – 5503 Notification to Branch of Pregnancy Page 83

OHP – 5503 Notification of Pregnancy Loss/Termination Page 84

OHP – 5503 Notification to Branch of Pregnancy Loss/Termination Page 85

OHP – 5503 Newborn Added to Case Page 86

OHP – 5503 Notification to Branch of Newborn Page 87

OHP – 5503 UF/AF Report Change Page 88

OHP – 5503 Notification to Branch of UF-FA Report Change Page 89

OHP – 5503 DCS Sanction Applied Page 90

OHP – 5503 Change to Case Page 91

OHP – 5503 Change of Address Page 92

OHP – 5503 Notification to Branch of Address Change Page 93

OHP – 5503 OHP Reopen/Restore Medical Page 94

OHP – 5503 Unable to Restore DU Closed Case Page 95

OHP – 5503 148 Sent Page 96

OHP – 5503 Health Insurance Premium Reimbursement (HIP) Page 97

OHP – 5503 OHP Client has or is Eligible for Medicare – Closure Page 98

OHP – 5503 CHIP with TPR Closure Page 99

OHP – 5503 CWM no CHIP Closure Page 100

OHP – 5503 Medical Case Closed Per Client Request Page 101

OHP – 5503 Case Transfer Page 102

OHP – 5503 Companion Case Transfer Page 103

OHP – 5503 FS Companion Case Transfer Page 104

OHP – 5503 5503 Medical Transportation Page 105

OHP – 5503 415H Sent to Client Page 106

OHP – 5503 Hearing Request Sent to Client Page 107

All Program Eligibility Narrative Version 1

1) General Application Information

a) Program(s) Applying For:

b) Case Number(s):

c) Date of Request:

d) Filing Date for FS:

e) Type of Interview/Contact (FTF, Mail, Phone, HV) and date:

F) receiving tribal TANF OR FOOD BENEFITS?:

g) expedited fs service (y/n and reason):

h) Alternate Format/Language:

i) Authorized Rep/Alternate Payee Name (231 or 7218 completed?) ID FOR FS AUTH REP AND ALL ALT PAYEES Verified by?:

j) does client want to register to vote? (MSC 0503):

k) Child Welfare Involvement? Consider for employment plans, if any:

l) Disability? Does anyone need an accommodation?

(For medical program Accommodations, call a medical program analyst.):

m) Release of Information Form Completed?:

n) Referrals?:

2) Non-Financial Requirements/Information

A) Eligibility Groups:

i) Who is applying together?

ii) Who must apply together?

iii) Does everyone share food in the

HOusehold?

iv) Is anyone pregnant? If so, what is the due date?

Is the father of the unborn in the household?

b) ID:

c) Citizen/Alien Status (explain eligibility):

i) WAived for TANF/TA-DVS due to domestic violence (Y/N)

ii) Is anyone required to meet DRA citizenship documentation (Y/N)

(List who needs documentation; what documents were used to verify ID and citizenship for each person; Cit field information)

d) SSN (how verified?):

e) Residency (Oregon resident, not questionable?):

f) Cooperation with DCS (including CASH medical support):

i) Absent Parents/FLS 112 (112 is not required for medical applicants)?

ii) Father of UB, if not in household?

iii) Good Cause for noncooperation with child support (428A/8660)?

iv) Send address of record or claim of risk information to DCS?

g) Deprivation (needed for TANF, MAA, MAF):

i) Who is the caretaker relative(s)? If because of UB only, what is DUE?

ii) Waived pregnancy final month requirement for TANF/TA-DVS due to DV?

iii) Who is the PWE for two-parent based on UN?

iv) Did PWE quit job within last 12 months? If yes, was there good cause?

v) What is incapacity for two-parent based on incapacity? How verified?

vi) For TANF/MAA/MAF continued absence, how verified?

h) Student Status (explain eligibility for FS, TANF and OHP-OPU):

i) For OHP-OPU Only, Premium Requirement?:

j) pursuit of assets:

i) Existing or available health insurance? 415H and copies of health insurance cards to HIG?

ii) UC?

3) Financial Requirements/Information

a) Shelter (who is paying? how much?):

b) Utilities (justify standard used):

c) Resources (for TANF/MAA/MAF/OHP-OPU/OHP-CHP and FS non-categorically eligible household, including vehicles):

d) Income:

i) Earned Income (actual/anticipated/converted & how verified?):

ii) Screen Data:

WAGE

WORK #

DPPL

HINQ/SSNX

PESM, P

***Show Earned Income Calculation

iii) FS:

iv) ERDC:

v) MAA/TANF:

vi) TA-DVS (count only income immediately available):

vii) MAF:

viii) QMB:

ix) Other:

x) Medical Cost (FS only, for elderly/disabled, how verified?)

xi) Unearned Income (actual/anticipated/converted & how verified?)

xii) screen data:

ECLM

SMUX/SMR1

***Show Unearned Income Calculation

xii) FS:

xiv) ERDC:

xv) MAA/TANF:

xvi) TA-DVS (count only income immediately available):

xvii) MAF:

xviii) QMB:

xix) Other:

e) OHP Income Calculation (include need group size, self-employment issues):

DOR

Budget month used

Budget month income

Income one month prior to budget month

Income two months prior to budget month

Income three months prior to budget month

Three month average (list 3 months used for average)

Self-employed? 50% deduction or actual allowable deductions?

Equal to or less than 10% FPL for non-exempt OPU applicants?

f) For FS Only:

Step 1/Step 2 for NC2s with Income

Medical Cost (for elderly/disabled; how verified; none claimed?)

Court Ordered Support (NAME child outside of HH, how verified?)

G) Categorical EligibIlITY for FS:

Income Under 185% FPL?

3400 Given?

If Not CAT EL, Why?

h) Child/Dependent Care Cost:

Ongoing Copay:

Reduced Copay (RCP) Month?

Child Care Hours:

Child Care Providers:

Immunization Records:

i) If Zero Income, How are Applicants Meeting Basic Needs? IF HELP FROM FAMILY/FRIENDS, WHAT FORM OF HELP AND HOW VERIFIED?:

4) FS Employment Requirements

a) 30-day Job Quit for FS (good cause?):

b) OFSET Status/Plan (if exempt/disqualified, why)?:

5) TANF JOBS Status/Plan (DHS 7823/SIGNED 7819)

(No JOBS Requirement for MAA/MAF)

6) TA-DVS/TANF When Risk of Domestic Violence

Do not use this addendum on-line if you have any concerns about access by other DHS or partner agencies.

DO NOT COMPLETE THIS FORM ON-LINE IF:

* THE ABUSER LIVES IN THE HOUSEHOLD, OR

* IF YOU BELIEVE THE ABUSER HAS ACCESS TO TRACS.

a) Immediate safety assessed within 8 working hours (Y/N):

b) List safety concerns:

c) Abuser's name:

d) Requirements waived for TANF/TA-DVS Due to Domestic Violence (Cannot be waived for MAA):

e) DVAA (1543) Completed or Scheduled to Be Completed (Date):

f) Resources Offered until DVAA Can Be Completed:

7) Eligibility Decision:

a) Pended

i) Why?

ii) What is the 30th/45th day?

iii) Was BED coding added to prevent automatic closure of medical or TANF?

iv) CID, CIE, CIP needed for medical?

b) Denied

i) Why?

ii) 462/456 notices sent?

iii) If the client is disabled and medical denied, was OSIPM presumptive referral made to SPD? to what branch?

c) Approved:

i) FS:

Effective date?

When does the cert end?

Reporting method?

ii) TANF:

What is the next review date?

Reporting method?

Referred for SFPSS?

iii) MAA:

What is the next review date?

When was each person’s medical started?

If the medical start date is different from the DOR, why?

Is there any retroactive medical eligibility?

Reporting method?

Managed health plan or PCM?

iv) MAF:

What is the next review date?

When was each person’s medical started?

If the medical start date is different from the DOR, why?

Is there any retroactive medical eligibility?

Reporting method?

Managed health plan or PCM?

v) ERDC:

What is the next APR date?

What is the reduced co-pay month (RCP)?

What is the ongoing co-pay?

vi) TA-DVS:

90 day eligibility period from__________ to__________.

Second or subsequent request within 12 month period (Y/N):

If yes, staffed with central office (Y/N).

If approved, 456DV given (Y/N):

If denied, 456 given with denial reason of:

vii) OHP:

Certification period for each person?

When was each person’s medical started?

If the medical start date is different from the DOR, why?

Managed health plan or PCM?

d) Other Program(s): Approved? Pended? Denied (462/456)? Why?

8) Additional Comments:

All Program Eligibility Narrative Version 2

1) General Application Information

a) Program(s) Applying for:

b) Case number(S):

c) Date of request:

d) Filing Date for FS:

e) Type of Interview/Contact (FTF, Mail, Phone, HV) and date:

f) Eligible for Tribal tanF OR FOOD BENEFITS?:

G) Expedited FS Service (Y/N & Reason):

H) Alternate Format/Language:

I) Authorized Rep/Alternate Payee Name (231 or 7218 completed?). ID FOR FS AUTH REP AND ALL ALT PAYEES VERIFIED BY?:

J) Remember to explain to clients about Voter Registration (MSC 0503):

K) Child Welfare Involvement:

L) Disability? Does anyone need an accommodation?

For medical program Accommodations, call a medical program analyst.:

M) Release of Information Form Completed?:

N) Referrals:

2) Non-Financial Requirements/Information

A) Eligibility Groups:

i) Who is applying together?

ii) Who must apply together?

iii) Does everyone share food in the

HOusehold?

iv) Is anyone pregnant? If so, what is the due date?

B) ID:

C) Citizenship/Alien Status: Waived for TANF/TA-DVS for domestic violence? (List who needs documentation; what documents were used to verify ID and citizenship for each person; Cit field information)

D) SSN (how verified?):

E) Residency (Oregon resident, not questionable?)

F) Cooperation with DCS (including cash medical support):

G) Deprivation (Needed for TANF, MAA, MAF):

H) Student Status (explain eligibility for FS, TANF and OHP- OPU):

I) For OHP-OPU Only, Premium Requirement?:

J) TPR?

3) Financial Requirements/Information

(a) Shelter (Who is paying? How much?)

(b) Utilities (JUSTIFY STANDARD USED)

(c) Resources (for TANF/MAA/MAF/OHP-OPU/OHP-CHP and FS non-categorically eligible household, including vehicles):

(d) Income

Earned Income (actual/anticipated & how verified?):

(i) Screen Data:

WAGE:

WORK #:

DPPL:

HINQ / SSNX:

PESM, P:

***Show earned income calculation for each program:

Unearned Income (actual /anticipated & how verified?):

(ii) screen data:

ECLM

SMUX, SMR1

***Show unearned income calculation for each program:

(E) OHP Income Calculation (Include Need Group Size, Self-employment issues)

Show Calculation:

Budget Month?

3 Month Average?

(F) For FS Only:

Step 1 / Step 2 For NC2s With Income:

Income Under 185% FPL?

dHS 3400 GIVEN?

IF NOT CAT EL, WHY?

Court Ordered Support (NAME child outside of HH, how verified?)

Medical Costs?

(g) Child / Dependent Care Cost:

On-going Copay:

Reduced Copay (RCP) for This Month?

Child Care Hours:

Child Care Providers:

Immunization Records:

(H) If Zero Income, How Meeting Basic Needs? IF HELP FROM FAMILY/FRIENDS, HOW IS HELP RECEIVED AND HOW VERIFIED?

4) FS Employment Requirements

30-Day Job Quit For FS (Good Cause?):

OFSET Status / Plan (If Exempt/Disqualified, Why?):

5) Jobs Status/Plan/Include TA-DVS

6) TANF When Risk for DV:

7) Eligibility Decision

Food Stamps:

TANF:

ERDC:

MAA / MAF:

OHP:

Other Medical Program:

OHP Cert Period/MAA/MAF (or Other Medical) Review Date?

Health insurance Information (Plans Chosen; HNA?)

Reporting System(s):

Pended For:

Denied:

8) Additional Comments:

All Program Eligibility Narrative Version 3

1) General Application Information

Explain the circumstances (what/why are they applying, who is applying, is anyone pregnant, what’s the DOR/filing date, alternate format, language)?

2) Non-Financial Requirements/Information

ID

Citizen/Alien Status

SSN

Residency

Eligibility groups

DCS Cooperation (including Cash medical support)

Deprivation

Student Status

3) Non-Financial Requirements/Information & TA-DVS TANF when risk of domestic violence

4) Financial Requirements/Information

Shelter

Utilities

Resources

Income (earned and unearned, pay dates, YTD totals)

FS child care DEDUCTION

FS medical DEDUCTION

FS COURT-ORDERED SUPPORT DEDUCTION

Categorically eligible for FS?

5 ) FS Employment Requirements & TANF JOBS Status/Plan

JOBS/OFSET?

6 ) Eligibility Decision (include next Review/Recert Date)

Reporting Method

Health Plan

Forms

ALL PROGRAM ELIGIBILITY NARRATIVE VERSION #4

1) GENERAL APPLICATION/NON-FINANCIAL INFORMATION

A. PROGRAM(S) APPLYING FOR:

B. CASE NAME:

C. CASE NUMBER(S):

D. DATE OF REQUEST:

E. FILING DATE:

F. INTERVIEW DATE:

G. TYPE OF INTERVIEW (FTF, MAIL, PHONE, HV):

H. ALTERNATE FORMAT/LANGUAGE:

I. EXPEDITED FS SERVICE (Y/N & REASON):

J. AUTHORIZED REP/ALTERNATE PAYEE NAME (231/7218 COMPLETED?). ID FOR FS AUTH REP AND ALL ALT PAYEES VERIFIED BY?:

2) HOUSEHOLDCOMPOSITION/CITIZENSHIP/ID/SSN/RESIDENCY

A. WHO’S IN HH?:

B. filing group(s)?:

C. Fleeing felon (FS & TANF only):

d. ANYONE PREGNANT? WHO AND DUE DATE?:

e. ID (DOES IT MEET FS AND MEDICAID REQUIREMENTS?:

f. CITIZENSHIP STATUS:

WHO NEEDS TO MEET DRA CITIZENSHIP REQUIREMENTS?:

DOCUMENTS USED FOR CITizenSHIP AND ID (LIST BY PERSON):

ARE CIT FIELDS UPDATED FOR ALL?:

G. alien status?:

H. SSN (ALIAS SSN?):

I. RESIDENCY:

J. TRIBAL verification?:

Receiving any Tribal benefits?:

Enroll in medical/dental plan?:

K. STUDENT STATUS:

3) HOUSEHOLD INCOME

A. EARNED INCOME:

WAGE:

DPPL:

HINQ/SSNX/PESM (PESM,P,provider # enter):

THE WORK NUMBER:

SHOW EARNED INCOME CALCULATION:

B. UNEARNED INCOME:

ECLM:

SMUX/SMR1:

grant:

SHOW UNEARNED INCOME CALCULATION:

C. IF ZERO INCOME, HOW MEETING BASIC NEEDS?:

(IF STATES HELP FROM FAMILY/FRIENDS, WHAT IS THE FORM OF THIS HELP? HOW WAS IT VERIFIED?):

4) FOOD STAMPS

A. STEP 1/STEP 2 FOR NC2'S WITH INCOME:

B. 3400 GIVEN?:

C. INCOME UNDER 185% FPL?:

D. CAT ELIG? IF NO, WHY?:

e. 30-DAY JOB QUIT FOR FS (GOOD CAUSE?):

f. OFSET STATUS/PLAN (IF EXEMPT/DISQUALIFIED, WHY?):

5) FOOD STAMP DEDUCTIONS

A. SHELTER (WHO IS PAYING? HOW MUCH?):

B. UTILITIES:

C. COS (FOR CHILD OUTSIDE OF HH, HOW VERIFIED?):

D. MEDICAL COSTS (FOR ELDERLY/DISABLED, HOW VERIFIED? AMOUNTS?):

E. CHILDCARE COSTS:

6) ERDC and TANF CHILD CARE

A. CHILD/DEPENDENT CARE COST:

B. COPAY: rcp month?:

C. OTHER COSTS NOT PAID BY DHS:

D. CHILD CARE HOURS:

E. IMMUNIZATIONS UP TO DATE:

F. PROVIDER NAME AND NUMBER:

7) TANF/MAA/MAF

A. BASIS OF DEPRIVATION:

B. ABSENT PARENTS:

C. PWE (WHO AND HOW DETERMINED):

D. 12-MONTH JOB QUIT FOR TANF (GOOD CAUSE?):

E. PURSUING ASSETS?

F. DISABLED (Who, how; documented):

G. BUDGET MONTH?:

H. TANF ONLY (DOESN’T AFFECT MEDICAL): FLEEING FELON?:

8) CHILD WELFARE INVOLVEMENT?

9) TANF JOBS MANDATORY?

A. PLAN (7823/7819 signed?):

10) TA-DVS/TANF WHEN RISK OF DOMESTIC VIOLENCE

A. IMMEDIATE SAFETY ASSESSED WITHIN 8 WORKING HOURS (Y/N):

B. LIST SAFETY CONCERNS:

C. ABUSER S NAME:

D. REQUIREMENTS WAIVED FOR TANF/TA-DVS DUE TO DV (CANNOT BE WAIVED FOR MAA):

E. DVAA (1543) COMPLETED OR SCHEDULED TO BE COMPLETE (DATE)?:

F. RESOURCES OFFERED UNTIL dVAA CAN BE COMPLETED?:

G) Beginning date TA-DVS eligibility:

H) End date TA-DVS eligibility:

I) Staffed with ___________(Name of Analyst) if TA-DVS received within the last 12 months.

11) MEDICAL (REVIEW FOR MAA/MAF FIRST AS ABOVE, THEN OHP)

A. BUDGET MONTH? (START WITH DOR MONTH AND “FLOAT” BUDGET MONTH IF NECESSARY):

B. SELF-EMPLOYED? USING 50%/ OR ACTUAL DEDUCTIONS?:

C. GROSS INCOME FOR BUDGET MONTH:

D. GROSS INCOME FOR LAST MONTH:

E. GROSS INCOME FOR 2 MONTHS AGO:

F. GROSS INCOME FOR 3 MONTHS AGO:

G. 3-MONTH AVERAGE:

H. EQUAL TO OR LESS THAN 10% FPL FOR NON-EXEMPT OPU?:

12) FOR ALL MEDICAL

A. ENROLLMENT:

B. TPR/ESI AVAILABLE?:

C. 415H COMPLETED AND SENT TO HIG? GROUP INSURANCE FORM 422-091 TO FHIAP?:

D. pursuit of assets:

e. HIP?:

13) RESOURCES (FOR TANF/MAA/MAF/OPU/CHP AND FS NON-CAT)

A. CHECKING:

B SAVINGS:

C. OTHER:

D. VEHICLE (WVIR):

14) PENDED FOR? INCLUDE PROGRAM(S) AND date(s) DUE

15) ELIGIBILITY DECISION/CERT PERIOD:

A. FOOD STAMPS:

B. TANF:

C. ERDC:

D. MAA/MAF:

E. OHP:

F. OTHER MEDICAL PROGRAM:

G. TA-DVS:

16) GENERIC INFORMATION

A. DOES CLIENT WANT TO REGISTER TO VOTE?:

B. REPORTING SYSTEM ASSIGNED:

C. RELEASE OF INFO OBTAINED:

D. APPLICATION SIGNED, DATED AND IN FILE?:

E. REFERRALS:

17) ADDITIONAL COMMENTS:

ERDC ONLY PROGRAM ELIGIBILITY NARRATIVE

1) NAME:

2) CASE NUMBER:

3) DATE OF REQUEST:

4) INTERVIEW DATE:

5) TYPE OF INTERVIEW (FTF, MAIL, PHONE, HV):

6) RESIDENCY:

7) ALTERNATE FORMAT/LANGUAGE:

8) AUTHORIZED REP/ALTERNATE PAYEE NAME (231 COMPLETED?)

9) HOUSEHOLD COMPOSITION (LIST EVERYONE IN THE HOUSEHOLD):

10) CITIZENSHIP/ALIEN STATUS:

11) WAIVED FOR DV?

12) SAVE CHECKED?

13) WHO NEEDS CHILD CARE?

14) SNA/SNR FOR ANY CHILDREN?

15) IMMUNIZATIONS UP TO DATE:

16) EXCEPTIONS RECEIVED:

17) EARNED INCOME:

WAGE:

DPPL:

HINQ/SSNX/PESM (PESM,P,provider # enter):

THE WORK NUMBER:

18) HISTORICAL REPRESENTATIVE OF FUTURE INCOME?

IF NOT, WHY?

19) SHOW CALCULATION:

20) UNEARNED INCOME:

ECLM:

SMUX/SMR1:

21) SHOW CALCULATION:

22) WORK HOURS/DAYS:

CHILD CARE HOURS:

23) PROVIDER NAME AND NUMBER – PRIMARY:

PROVIDER NAME AND NUMBER – SECONDARY:

24) COPAY:

RCP MONTH IF ELIGIBLE:

25) STUDENT STATUS:

WORK STUDY?:

26) APPLICATION SIGNED, DATED AND IN FILE?:

27) DOES CLIENT WANT TO REGISTER TO VOTE?:

28) RELEASE OF INFO OBTAINED:

29) ELIGIBILITY DECISION/CERT PERIOD:

30) PENDED FOR?:

31) REFERRALS:

32) ADDITIONAL COMMENTS:

CCB Information to DPU

1. Branch #:

2. Worker:

3. Case #:

4. Case Name:

5. Provider #:

6. Provider Name:

7. Primary Provider:

8. Replaces Another Provider?:

9. If So, Who?:

10. Date Care Began:

11. CC Work Hours:

12. Eligible RCP?:

13. Copay:

14. Comments:

Domestic Violence Assistance Agreement - TRACS Supplement

DO NOT COMPLETE THIS FORM ON-LINE IF:

(1) THE ABUSER LIVES IN THE HOUSEHOLD, OR

(2) IF YOU BELIEVE THE ABUSER HAS ACCESS TO TRACS

DO NOT USE THIS SUPPLEMENT IF YOU ARE COMPLETING A DHS 1543

1. Use PDP with steps/actions to address safety and/or stabilization:

2. Safe address/contact information:

3. Partner coordination/referrals:

4. Agreed upon/actual support service payments:

5. Agreed upon/actual TA-DVS payments:

6. Plan to address future housing costs if on-going resources unavailable:

7. Follow-up appointment (if applicable):

8. Misc. information about any follow-up or special request of the client:

TA-DVS Eligibility and Assessment Addendum (OPTIONAL USE ONLY)

Safety is the Primary Concern when working with Survivors of Domestic Violence. This addendum should only list information regarding adult victims. Do not use this addendum on-line if you have any concerns about access by other DHS or partner agencies.

DO NOT COMPLETE THIS FORM ON-LINE IF:

* THE ABUSER LIVES IN THE HOUSEHOLD, OR

* IF YOU BELIEVE THE ABUSER HAS ACCESS TO TRACS.

I. ELIGIBILITY QUICK REFERENCE SECTION:

(For additional information and appropriate questions see section II)

1. Phone or paper application (415F) completed:

2. Safety assessed within 8 working hours of phone/paper application (DHS 7802- optional)

3. Eligibility determined with 16 working hours:

4. Safety Concerns identified: (See possible questions below)

*current or past physical/sexual abuse, describe:

*fear of or threats of physical/sexual abuse, describe:

*verbal or emotional abuse, describe:

*controlling or coercive behavior, describe:

*other:

(may not be eligible refer to TA-DVS section of FSM.)

5. Abuser is:

*Household member current/past

*Family member current/past

*Intimate partner current/past

*other:

(may not be eligible - refer to TA-DVS section of FSM)

6. Client is care taker relative:

*if pregnant (can be at any point of pregnancy), due date:

*is minor child in home?

*if not, when expected?

(If more than 90 days staff with line manager or central office)

7. Available Income below TANF income standard: (Use DHS 1542 - Income Calculation form - optional)

*Source of income:

*When available:

CONTACT CENTRAL OFFICE FOR JOINT APPROVAL IF SECOND OR SUBSEQUENT REQUEST WITHIN 12 MONTHS.

If Eligible:

8. Give 456DV - note eligibility dates:

9. DVS N/R coded with first month of eligibility

10. If any TANF requirements are waived - code on PDP

11. Complete DHS 1543 - Domestic Violence Assistance Agreement

If ineligible:

10. Give 456 - denial reason

II. GUIDED ELIGIBILITY SECTION - SEE BELOW

QUESTIONS TO HELP IDENTIFY SAFETY CONCERNS:

*Interview the client in a private-confidential location*

1. WHAT ARE YOUR IMMEDIATE SAFETY CONCERNS OR WHAT BROUGHT YOU HERE TODAY?

*physical injury, fear of physical injury, sex abuse, mental, emotional or verbal abuse, coercive and controlling behavior

2. ARE YOU AFRAID TO GO HOME? ANYWHERE ELSE?

*If yes, do you want police intervention?*

3. WHAT DO YOU NEED TO KEEP YOU AND YOUR CHILD(REN)

SAFE?

*Consider consulting with the DV program before

developing a plan with the survivor.*

ASSESSING THE NEEDS:

4. HAVE YOU OR DO YOU (OR YOUR CHILDREN) NEED TO SEE A

DOCTOR?

*Explain mandatory reporting requirements if children

have been hurt or at serious risk.*

5. WHAT IS THE ABUSERS NAME?

The abuser must be an intimate partner; family member; household member*

6. WHAT KIND OF HELP HAVE YOU TRIED TO ACCESS?

DV Service Provider?

Police?

Victim's Assistance?

Family?

Friend?

Other:

7. IF YOU LEFT BEFORE, WHAT WORKED?

8. DO YOU HAVE A RESTRAINING ORDER OR A NO CONTACT ORDER?

*If the client has a restraining order, ask for a copy

for the file. Make clear that it is for safety reasons,

not for verification.*

9. WE KNOW THAT THIS CAN BE A VERY STRESSFUL TIME, HOW

ARE YOU FEELING? DO YOU NEED TO TALK WITH SOMEONE?

*Depending upon the response, refer the client to the DV service provider; support group or counseling as

appropriate.*

IF THE CLIENT WANTS TO FLEE:

10. WHERE ARE YOU STAYING NOW? IS THIS A SAFE PLACE TO

STAY, TEMPORARILY?

*If no, consider referral to a shelter or provide a hotel voucher.*

*If yes, how long can you stay?*

11. DO YOU WANT TO STAY IN THE AREA OR DO YOU WANT TO GO

TO ANOTHER TOWN/STATE?

12. DOES YOUR ABUSER KNOW YOU WANT TO LEAVE?

*If not, ask how the abuser is likely to respond.*

13. DOES YOUR ABUSER WORK?

WHAT HOURS?

IF THE CLIENT WANTS TO STAY AT HOME:

14. IS THE ABUSER LIKELY TO BREAK IN?

15. DO YOU NEED LOCKS CHANGED?

16. HOW DO YOU THINK WE CAN HELP YOU BE SAFER AT HOME?

17. HAVE YOU WORKED OUT A PLAN TO BE SAFE AT HOME?

*Always consult with a domestic violence program if the survivor is planning to stay in a home with the abuser.*

HOUSEHOLD COMPOSITION:

18. IS THE SURVIVOR PREGNANT?

*If yes, what is the due date?*

19. DOES THE SURVIVOR HAVE ACCESS TO PRE-NATAL CARE?

20. ARE THEIR CHILDREN LIVING IN THE HOUSEHOLD?

*If no, where are they staying?*

*When are they expected to return?*

21. IS THE CLIENT LIVING IN A SHELTER?

*Is she working with an advocate or case manager

(get their name)?*

22. IS IT SAFE TO MAIL INFORMATION ABOUT YOUR CASE TO

YOUR HOME?

*If no, what address can we use that is safe?*

23. INCOME - Refer to Income calculation form DHS 1542:

24. BASED ON THE 1542 ARE THERE FUNDS AVAILABLE IN TIME TO MEET THE URVIVOR'S SAFETY CONCERNS?

WORKER USE ONLY:

25. IF ELIGIBILITY IS APPROVED (GIVE 456DV)

*Enter DVS Needs/Resource code on PCMS

*Enter DV waiver code if appropriate

*Complete Domestic Violence Assistance Agreement (DHS 1543) with the client.

26. IF ELIGIBILITY IS DENIED (GIVE 456) WITH DENIAL REASON

INTERIM CHANGE REPORT NARRATIVE Version 1

1) Month Due:

2) Date Received:

3) Does client still live at the address on FSMIS?

If change of residence, list the following:

Shelter:

Utility standard and why:

4) Who lives at this address?

If any change in household composition:

List everyone in the household:

Explain how the filing group was determined:

SSN for new members:

Citizen/alien status for new members:

5) Is client or anyone in household a student?

STUDENT STATUS (why eligible or ineligible?):

6) Paying Child Support

If anyone in the filing group is court-ordered to pay child support, has the court- order changed?

7) Does anyone in finaNcial group work?

If yes, narrate income below.

WAGE:

DPPL:

HINQ:

The Work Number:

8) EARNED INCOME (Actual/Anticipated & How Verified?)

SHOW CALCULATION:

9) Does anyone in financial group get money from any other source?

If yes narrate unearned income below

ECLM:

SMUX/SMR1:

10) UNEARNED INCOME (Actual/Anticipated & How Verified?)

SHOW CALCULATION:

Fifth month’s income used? Why or why not?

11) all information available to the Department Checked?

12) INCOMPETE REPORT

What is missing?

Date 487 sent and due?

13) Impact of reported change on other open programs

TANF:

MEDICAL:

14) ADDITIONAL COMMENTS:

Interim Change Report (852) Template Version 2

1) Date Received:

2) Month due:

3) Pended for:

4) Date DHS 487 mailed:

5) Any change in address, shelter or utility costs?

If yes, list change:

6) Household Composition:

If any changes, list everyone in the household and explain how the filing group was determined.

Clear SSN and citizen/alien status for new filing group members.

7) Student status (explain eligibility):

8) If court-ordered to pay child support, has the court- order changed?

9) Earned Income:

How Verified?

Checked WAGE, DPPL, HINQ/SSN, Work number?

Show Calculation:

10) Unearned Income:

How Verified?

Checked ECLM, SMUX/SMR1?

Show Calculation:

11) Fifth month’s income used? Why or why not?

12) Decision:

13) Impact of reported change on other open programs

TANF:

MEDICAL:

14) Additional Comments:

Interim Change Report Narrative Template Version 3

1) Month due:

2) Date Received:

3) 487 (incomplete report) sent:

Requesting:

Due Back By:

4) HOUSING COSTS

Any residence change since cert?

Housing Cost (Rent, Mortgage if buying):

Pays for Heat (Yes or No):

Explain utility standard allowed:

5) HOUSEHOLD COMPOSITION

If any changes, list all household members:

Explain how filing group was determined:

SSN for new members:

Citizen/alien status for new members:

Student status (explain eligibility):

6) COURT-ORDERED SUPPORT

If anyone in the filing group is court-ordered to pay child support, has the court-order changed?

How much paid and how verified:

7) EMPLOYMENT

Earned income ( Who’s working where: actual, anticipated & how verified):

DPPL:

SSNX/HINQ:

The Work Number:

WAGE:

Show Calculation:

8) UNEARNED INCOME

Unearned income (Who’s receiving & why: actual, anticipated & how verified):

ECLM:

SMUX/SMR1:

Show Calculation:

Fifth month’s income used? Why or why not?

9) DECISION:

10) Impact of reported change on other open programs

TANF:

MEDICAL:

11) ADDITIONAL COMMENTS:

FS ONLY Eligibility Narrative

1) CASE NUMBER:

2) FILING DATE:

3) INTERVIEW DATE AND TYPE:

4) IF PHONE INTERVIEW, REASON FOR WAIVING FACE-TO-FACE:

5) ALTERNATE FORMAT REQUESTED?:

6) ELIGIBLE FOR EXPEDITED SERVICE? WHY OR WHY NOT?:

7) DOES CLIENT WANT TO REGISTER TO VOTE?:

8) HOUSEHOLD COMPOSITION:

9) LIST EVERYONE IN THE HOUSEHOLD AND EXPLAIN HOW FILING GROUP WAS DETERMINED:

10) FLEEING FELON?:

11) AUTHORIZED REPRESENTATIVE?:

12) ALTERNATE PAYEE?:

13) ID FOR AUTH REP AND ALT PAYEE VERIFIED?:

14) DOES ANY FILING GROUP MEMBER RECEIVE TRIBAL FOOD DISTRIBUTION PROGRAM BENEFITS?:

15) RESIDENCY – DOES CLIENT INTEND TO REMAIN IN OREGON?:

16) SOCIAL SECURITY NUMBER FOR EACH MEMBER OF THE FILING GROUP – HOW VERIFIED?:

17) ID VERIFIED FOR HEAD OF HOUSEHOLD – HOW?:

18) CITIZENSHIP OR ALIEN STATUS FOR EACH FILING GROUP MEMBER:

IMMIGRATION DOCUMENT PRESENTED – RESULTS FROM SAVE:

19) STUDENT STATUS:

20) EARNED INCOME:

WHO WORKS? WHERE? HOW WAS INCOME VERIFIED? INTERVAL OF PAY DATES?

DPPL:

SSNX/HINQ/PESM:

THE WORK NUMBER:

WAGE:

SHOW EARNED INCOME CALCULATION:

21) UNEARNED INCOME:

WHOSE INCOME? HOW VERIFIED? INTERVAL OF PAYMENTS:

ECLM:

SMUX/SMR1:

SHOW UNEARNED INCOME CALCULATION:

22) CATEGORICAL ELIGIBILITY:

INCOME UNDER 185% FPL:

DHS 3400 GIVEN:

IF NOT CAT EL, WHY?:

23) RESOURCES (ONLY IF NOT CAT EL):

24) JOB QUIT WITHIN LAST 30 DAYS?:

WHO?:

GOOD CAUSE?:

25) IF ZERO INCOME, HOW IS APPLICANT MEETING NEEDS?:

26) DEDUCTIONS? HOW VERIFIED?:

CHILD CARE:

NAME OF CHILD IN CARE, CLIENT COST INCLUDING COPAY:

(CHECK WCMI FOR COPAY AMOUNT)

27) TOTAL SHELTER COST:

SHELTER COST PAID OR INCURRED BY APPLICANT:

SHELTER PRORATION (INELIGIBLE STUDENT, NC1):

28) UTILITY STANDARD ALLOWED AND WHY:

29) COURT-ORDERED CHILD SUPPORT (Y?N):

WHO PAYS? HOW VERIFIED?

PAID FOR WHICH CHILD OUTSIDE THE HOUSEHOLD?

30) MEDICAL DEDUCTION:

WHOSE COSTS? HOW VERIFIED? SHOW CALCULATION FOR ANTICIPATED COSTS:

31) NC2 CALCULATIONS:

NC2 STEP 1:

NC2 STEP 2:

32) OFSET STATUS – IF EXEMPT, WHY?:

IF DISQUALIFIED, WHY?:

REFERRAL MADE:

33) RIGHTS & RESPONSIBILITES EXPLAINED AND GIVEN:

34) ELIGIBILITY DECISION:

IF PENDED, LIST PENDING ITEMS AND DUE DATE:

IF DENIED, WHY? NOTICE SENT ON DATE:

IF CERTIFIED, WHAT IS CERT PERIOD?:

REPORTING SYSTEM ASSIGNED:

35) ADDITIONAL COMMENTS:

COMBINED ERDC AND FS Narrative

1) CASE NUMBER:

2) FILING DATE:

3) erdc date of request:

4) INTERVIEW DATE AND TYPE (ftf, mail, phone, hv):

5) IF PHONE INTERVIEW, REASON FOR WAIVING FACE-TO-FACE:

6) ALTERNATE FORMAT REQUESTED?:

7) ELIGIBLE FOR EXPEDITED SERVICE? WHY OR WHY NOT?:

8) DOES CLIENT WANT TO REGISTER TO VOTE?:

9) HOUSEHOLD COMPOSITION:

10) LIST EVERYONE IN THE HOUSEHOLD AND EXPLAIN HOW FILING GROUP(s) were DETERMINED:

11) for FS, FLEEING FELON?:

12) AUTHORIZED REPRESENTATIVE?:

13) ALTERNATE PAYEE?:

14) ID FOR AUTH REP AND ALT PAYEE VERIFIED?:

15) who needs daycare?

16) sna/snr for any children?

17) IMMUNIZATIONS UP TO DATE?

EXCEPTIONS RECEIVED:

18) DOES ANY FILING GROUP MEMBER RECEIVE TRIBAL FOOD DISTRIBUTION PROGRAM BENEFITS?:

19) RESIDENCY – DOES CLIENT INTEND TO REMAIN IN OREGON?:

20) SOCIAL SECURITY NUMBER FOR EACH MEMBER OF THE FILING GROUP – HOW VERIFIED?:

21) ID VERIFIED FOR HEAD OF HOUSEHOLD – HOW?:

22) CITIZENSHIP OR ALIEN STATUS FOR EACH FILING GROUP MEMBER:

IMMIGRATION DOCUMENT PRESENTED – RESULTS FROM SAVE:

23) STUDENT STATUS:

WORK STUDY?:

24) EARNED INCOME:

WHO WORKS? WHERE?

WORK HOURS/DAYS: CHILD CARE HOURS:

HOW WAS INCOME VERIFIED? INTERVAL OF PAY DATES?

25) SCREEN DATA:

DPPL:

SSNX/HINQ/PESM:

THE WORK NUMBER:

WAGE:

26) SHOW EARNED INCOME CALCULATION:

27) UNEARNED INCOME:

WHOSE INCOME? HOW VERIFIED? INTERVAL OF PAYMENTS:

ECLM:

SMUX/SMR1:

SHOW UNEARNED INCOME CALCULATION:

28) CATEGORICAL ELIGIBILITY:

INCOME UNDER 185% FPL:

DHS 3400 GIVEN:

IF NOT CAT EL, WHY?:

29) RESOURCES (ONLY IF NOT CAT EL):

30) JOB QUIT WITHIN LAST 30 DAYS?:

WHO?:

GOOD CAUSE?:

31) PROVIDER NAME AND NUMBER – PRIMARY:

PROVIDER NAME AND NUMBER – SECONDARY:

32) NAME OF CHILD IN CARE/CLIENT COST INCLUDING COPAY:

COPAY:

RCP MONTH IF ELIGIBLE:

33) DEDUCTIONS? HOW VERIFIED?:

(a) FS CC deduction amount

(B) TOTAL SHELTER COST:

SHELTER COST PAID OR INCURRED BY APPLICANT:

SHELTER PRORATION (INELIGIBLE STUDENT, NC1):

(c) UTILITY STANDARD ALLOWED AND WHY:

(D) COURT-ORDERED CHILD SUPPORT (Y?N):

WHO PAYS? HOW VERIFIED?

PAID FOR WHICH CHILD OUTSIDE THE HOUSEHOLD?

(E) MEDICAL DEDUCTION:

WHOSE COSTS? HOW VERIFIED? SHOW CALCULATION FOR ANTICIPATED COSTS:

34) NC2 CALCULATIONS:

NC2 STEP 1:

NC2 STEP 2:

35) OFSET STATUS – IF EXEMPT, WHY?:

IF DISQUALIFIED, WHY?:

REFERRAL MADE:

36) RIGHTS & RESPONSIBILITES EXPLAINED AND GIVEN:

RELEASE OF INFO OBTAINED:

37) ELIGIBILITY DECISION:

IF PENDED, LIST PENDING ITEMS AND DUE DATE:

IF DENIED, WHY? NOTICE SENT ON DATE:

IF CERTIFIED, WHAT IS CERT PERIOD?:

REPORTING SYSTEM(S) ASSIGNED:

38) REFERRALS:

39) ADDITIONAL COMMENTS:

BED DATE ADDED-BENEFITS RESTORED

1) CASE #:

2) DOR:

3) BED DATE:

4) ACTION ON CM case:

5) COMMENTS:

date of request BY PHONE/OFFICE CONTACT

USE WHEN DOR IS ESTABLISHED BY PHONE CALL OR OFFICE VISIT

1) CASE #:

2) WORKER:

3) NAME OF PERSON CALLING:

4) DOR:

5) ADDED BED DATE?

BED DATE:

6) HAS AN APPLICATION BEEN SENT IN (Y/N)?

7) WHEN WOULD BE THE BEST TIME FOR A WORKER TO CALL IF THEY HAVE QUESTIONS?

8) COMMENTS:

OHP APProval combined with OPu no program available denial

1. WORKER/ID:

2. CASE#:

3. IF REAPPLICATION, MONTH:

4. IF NEW APPLICATION, DOR:

5. DATE RECEIVED:

6. If client indicated they have a disability, did you send the presumptive referral? To what branch?

7. If you denied any adults because no program was available did you send notice?:

8. 462A (Y/N)

9. 462C (Y/N) Use for new applicants only; if ongoing, refer to SPD and keep on OHP during SPD referral process.

10. COMMENTS:

11. # IN NEED GROUP:

IS ANYONE PREGNANT? IS THE FATHER OF THE UB IN THE HOME?

ABSENT PARENT(S)?

12. IF OHP STANDARD (who):

Effective?:

sTUDENT STATUS?:

13. IF OHP PLUS (who):

Effective?:

14. TOTAL AVG INCOME:

15. TOTAL BUDMO INCOME:

16. Did you check ECLM/WAGE/SMUX/SMR1?

17. IF AUTHORIZED REPRESENTATIVE (who):

18. IF AUTHORIZATION TO RELEASE (who):

19. IF ALTERNATE FORMAT (what):

20. PLANS (medical/dental):

21. CITIZENSHIP STATUS:

WHO NEEDS TO MEET DRA CITIZENSHIP REQUIREMENTS?:

DOCUMENTS USED FOR CITIZENSHIP AND ID (LIST BY PERSON):

ARE THE CIT FIELDS UPDATED FOR ALL?:

22. NON-CITIZENS:

UNDOCUMENTED (who):

DOCUMENTED (Alien Status # & who):

INCOME BREAKDOWN

23. WHO:

IF ALIAS SSN:

INCOME TYPE:

INCOME SOURCE:

HOW OFTEN PAID:

24. LAST QTR ON WAGE:

25. MONTH:

26. MONTH:

27. MONTH:

28. BUDMO:

29. OHP-OPU PREMIUM REQUIREMENT (Mandatory? Exempt?):

30. TOTAL RESOURCES REPORTED:

(If more than zero, complete below)

31. CHECKING:

32. SAVINGS:

33. OTHER:

34. IS ESI/TPR AVAILABLE?:

(If yes, complete below)

35. WHO:

36. DATE REFERRED TO FHIAP:

37. 415H TO HIG?:

38. IF ELIGIBLE FOR HIP, AMOUNT:

39. IF 437 COMPLETED, AMOUNT:

APPROVED MEDICAL APPLICATION

1. WORKER/ID:

2. CASE#:

3. IF REDETERMINATION, MONTH:

4. IF NEW APPLICATION, DOR:

5. DATE RECEIVED:

6. COMMENTS:

7. # IN NEED GROUP:

IS ANYONE PREGNANT? IS THE FATHER OF THE UB IN THE HOME?

ABSENT PARENT(S)?

8. TOTAL AVG INCOME:

9. TOTAL BUDMO INCOME:

10. Did you check eclm/wage/smux/SMR1?

11. Benefits approved (who, what program, cert period)?:

12. IF AUTHORIZED REPRESENTATIVE (who):

13. IF AUTHORIZATION TO RELEASE (who):

14. IF ALTERNATE FORMAT (what):

15. PLANS (medical/dental):

16. CITIZENSHIP STATUS:

WHO NEEDS TO MEET DRA CITIZENSHIP REQUIREMENTS?:

DOCUMENTS USED FOR CITIZENSHIP AND ID (LIST BY PERSON):

ARE CIT FIELDS UPDATED FOR ALL?:

17. NON-CITIZENS:

18. UNDOCUMENTED (who):

19. DOCUMENTED (Alien Status # & who):

INCOME BREAKDOWN

20. WHO:

ALIAS SSN?:

INCOME TYPE:

INCOME SOURCE:

HOW OFTEN PAID?

21. LAST QTR ON WAGE:

22. MONTH:

MONTH:

MONTH:

23. BUDMO:

24. OHP-OPU PREMIUM REQUIREMENT (Mandatory? Exempt?):

25. TOTAL RESOURCES REPORTED:

(If more than zero, complete below)

26. CHECKING:

27. SAVINGS:

28. OTHER:

29. IS ESI/TPR AVAILABLE?:

(If yes, complete below)

30. WHO:

31. DATE REFERRED TO FHIAP:

32. 415H TO HIG?:

33. IF ELIGIBLE FOR HIP, AMOUNT:

34. IF 437 COMPLETED, AMOUNT:

NO MEDICAL PROGRAM AVAILABLE DENIAL

1. WORKER/ID:

2. CASE#:

3. DENIAL REASON(S): No program available

4. IF REAPPLICATION, MONTH:

5. IF NEW APPLICATION, DOR:

6. DATE RECEIVED:

7. If client indicated they have a disability, did you send the presumptive referral? to what branch?

8. If yes, did you send notice 462C?

9. If no, did you send notice 462A?

10. COMMENTS:

DUPLICATE/CONCURRENT DENIAL

1. WORKER/ID:

2. CASE #:

3. REASON DENIED: ALREADY RECEIVING BENEFITS.

4. IF REDETERMINATION/RECERTIFICATION, MONTH:

5. IF NEW APPLICATION, DOR:

6. DATE RECEIVED:

7. WAS A 148 NEEDED TO ADJUST DOR?:

(if yes, complete below)

8. NEW START DATE:

9. DATE 148 SUBMITTED:

10. WAS A DISCREPANCY FOUND?:

11. IF YES, ACTION TAKEN:

12. IF AUTHORIZED REPRESENTATIVE (who):

13. IF AUTHORIZATION TO RELEASE (who):

14. IF ALTERNATE FORMAT (what):

15. Comments:

DENIED or CLOSED OHP ONLY APPLICATION

1. woRKER/ID:

2. CASE#:

3. DENIAL REASON(S):

4. IF REAPPLICATION, MONTH:

5. IF NEW APPLICATION, DOR:

6. DATE RECEIVED:

7. If client indicated they have a disability, did you send the presumptive referral?

8. COMMENTS:

9. # IN NEED GROUP:

IS ANYONE PREGNANT? IS THE FATHER OF THE UB IN THE HOME?

ABSENT PARENT(S)?

10. IF OHP STANDARD (who):

11. IF OHP PLUS (who):

12. TOTAL AVG INCOME:

13. TOTAL BUDMO INCOME:

14. Did you check ECLM/WAGE/SMUX/SMR1?

15. IF AUTHORIZED REPRESENTATIVE (who):

16. IF AUTHORIZATION TO RELEASE (who):

17. IF ALTERNATE FORMAT (what):

CITIZENSHIP/STATUS

18. CITIZENS: Is anyone required to meet DRA citizenship documentation (Y/N)

List who needs documentation; what documents were used to verify ID and citizenship for each person; update Cit fields on Person/Alias Update.

19. NON-CITIZENS:

20. UNDOCUMENTED (who):

21. DOCUMENTED (Alien Status # & who):

INCOME BREAKDOWN

22. WHO:

23. IF ALIAS SSN:

24. INCOME TYPE:

25. INCOME SOURCE:

26. How often paid?

27. LAST QTR ON WAGE:

28. MONTH:

29. MONTH:

30. MONTH:

31. BUDMO:

32. TOTAL RESOURCES REPORTED:

(If more than zero, complete below)

33. CHECKING:

34. SAVINGS:

35. OTHER:

36. if applicants reported disability, OSIPM Presumptive referral? to what branch?

37. IS ESI/TPR AVAILABLE?:

(If yes, complete below)

38. WHO:

39. DATE REFERRED TO FHIAP:

(Note - there is no ESI or TPR for CHP/OPU)

40. 415H to HIG

EXT ELIGIBILITY DETERMINATION

1. Case Number:

2. Date of Determination:

3. REASON THAT MAA/MAF IS CLOSING:

4. Child support takes group over income limit:

5. Earned income increase takes family over income limit:

6. Other: Family is not eligible for EXT, but remember if DHS is acting on a reported change or if the client establishes DOR prior to closure of MAA/MAF, MAA/MAF can remain open if necessary during the 45 day pend:

7. FILING GROUP MEMBERS: (List names here and specify which one was eligible for and received MAA/MAF for at least 3 of the six months prior to the beginning of EXT):

8. Does the above filing group include at least one dependent child? (Choose one & delete the other options that do not apply):

9. Yes:

10. No (If this is the answer, there is no EXT eligibility.):

11. EXT ELIGIBILITY DETERMINATION (Choose one response, add info and delete other response language.):

12. Approved EXT – Start date is:

13. IE1/IE2/AE1/AE2 End date is:

(If opening at ie2, ae1 or ae2 level, send gsxtmed notice)

14. Not eligible and reason:

EXT MEDICAL QUARTERLY INCOME REPORT NARRATIVE – Version 1

1. RPT. MONTH DUE (By 21st):

2. DATE REC'D: FILE DATE:

3. CASE NUMBER:

4. CURRENT RPT. CODE:

5. REPORTED INCOME IN EACH of the THREE REPORTING MONTHS

(the 3 months before the report is due): (YES) (NO)? (Amount)?

6. NEW CODE/ACTION TAKEN:

7. FOOD STAMPS ACTION (YES) (NO)?

8. NEED to REVIEW for MAA/MAF?

EXT MEDICAL QUARTERLY REPORT NARRATIVE –Version 2

1. Report month due (By 21ST):

2. Date received:

3. If submitted late, Good Cause (Explain)?

4. Current EXT n/r code (IE1, IE2, AE1, or AE2) with end date:

5. Household composition:

6. Is there a dependent child in the EXT filing group?

7. Gross earnings for each month in quarter (Do not count unearned income):

a. 1ST Month:

b. 2ND Month :

c. 3RD Month :

8. Total gross earnings for quarter:

9. If no earnings in each month, Good Cause (Explain)?

10. Out of pocket child care expenses for each month in quarter?

a. 1ST Month:

b. 2ND Month:

c. 3RD Month:

11. Total CC costs for quarter:

12. Average Countable Earned Income (Total earnings minus Total out of pocket childcare expenses divided by 3 months):

13. Is the quarter’s averaged countable income under 185%?

14. New EXT n/r code (IE1, IE2, AE1 or AE2) with end date or other action taken:

15. Additional comments:

Note—The first Quarterly Report doesn’t affect eligibility unless they state that there is no dependent child or they moved out of State. We also need to consider that the report may result in an MAA eligibility decision.

MEDICAL ELIGIBILITY TEMPLATE

1. WORKER ID:

2. CASE#:

3. BUDGET MONTH USED:

4. DATE OF REQUEST:

5. DATE RECEIVED:

6. ALTERNATE FORMAT/LANGUAGE:

7. COMMENTS:

8. AUTHORIZED REP/ALTERNATE PAYEE NAME (231 COMPLETED?):

9. IF AUTHORIZED REPRESENTIVE (WHO):

10. IF AUTHORIZED TO RELEASE (WHO):

11. HOUSEHOLD COMPOSITION:

12. # IN FILING/NEED GROUPS:

IS ANYONE PREGNANT? IS THE FATHER OF THE UB IN THE HOME?

ABSENT PARENT(S)?

13. CITIZENSHIP/ALIEN STATUS (EXPLAIN ELIGIBILITY):

14. CITIZENS: Is anyone required to meet DRA citizenship documentation (Y/N):

List who needs documentation; what documents were used to verify ID AND CITIZENSHIP for each person; update Cit fields on Person/Alias Update.

15. NON-CITIZENS:

16. UNDOCUMENTED (who):

17. DOCUMENTED (alien status # & who):

18. ID/SSN (HOW VERIFIED?)

19. OREGON RESIDENT?

20. STUDENT STATUS (EXPLAIN ELIGIBILITY):

21. EARNED INCOME (ACTUAL/ANTICIPATED & HOW VERIFIED?):

22. WAGE:

23. DPPL:

24. ssnx/HINQ/pesm:

25. UNEARNED INCOME (ACTUAL/ANTICIPATED & HOW VERIFIED?):

26. ECLM:

27. SMUX/SMR1:

28. TOTAL INCOME:

29. IF ZERO INCOME, HOW MEETING BASIC NEEDS:

30. TOTAL RESOURCES REPORTED: $

(If more than zero, complete below)

31. CHECKING: $

32. SAVINGS: $

33. OTHER: $

34. DEPRIVATION (BASIS FOR MAA/MAF):

35. ABSENT PARENTS:

36. 12-MONTH JOB QUIT FOR 2 PARENT ONLY MAA/MAF PWE?:

37. DISABILITY?:

38. REFERRAL FOR PRESUMPTIVE ELIGIBILITY?:

39. HEALTH INSURANCE (PLANS CHOSEN; TPR; HNA):

40. IS ESI/TPR AVAILABLE?:

(If yes, complete below)

41. WHO:

42. APPLICATION SIGNED, DATED AND IN FILE?

43. REFERRALS: NONE

44. ELIGIBILITY DECISION:

45. OHP/MAA/MAF:

46. PENDED FOR?

47. ADDITIONAL COMMENTS:

TRACS OHP INTAKE FORM

1. DATE OF REQUEST:

2. FILING DATE:

3. HOUSEHOLD GROUP:

4. NEED GROUP:

IS ANYONE PREGNANT? IS THE FATHER OF THE UB IN THE HOME?

ABSENT PARENT(S)?

5. BENEFIT GROUP:

6. SSN:

7. CITIZENSHIP: Is anyone required to meet DRA citizenship documentation (Y/N):

List who needs documentation; what documents were used to verify ID and citizenship for each person; update Cit fields on Person/Alias Update.

8. ALIEN STATUS:

9. tribal verification?:

10. CHILD SUPPORT:

11. EARNED INCOME: BUDGET MO:

a. LAST MO:

b. 2 MOS AGO:

12. UNEARNED INCOME: BUDGET MO:

a. LAST MO:

b. 2 MOS AGO:

13. 3-MO AVG:

14. STUDENT?:

15. PELL GRANT?:

16. RESOURCES:

17. OTHER HEALTH COVERAGE (415H):

18. MEDICAL PLAN:

19. PREMIUMS / ARREARS?:

20. RIGHTS AND RESPONSIBILITIES / ALT. FORMAT:

21. ELIGIBILITY DECISION:

22. COMMENTS:

MEDICAL APPLICATION/REAPPLICATION NARRATIVE TEMPLATE

1. CASE NUMBER:

2. DATE OF REQUEST:

3. DATE RECEIVED:

4. ALTERNATE FORMAT/LANGUAGE:

Remember to explain to clients about Voter Registration (MSC 0503)

5. AUTHORIZED REP/ALTERNATE PAYEE NAME (231 COMPLETED?)

6. HOUSEHOLD COMPOSITION:

7. CITIZENSHIP/ALIEN STATUS (EXPLAIN ELIGIBILITY):

8. CITIZENS: Is anyone required to meet DRA citizenship documentation (Y/N):

List who needs documentation; what documents were used to verify ID and citizenship for each person; update Cit fields on Person/Alias Update.

9. ID/SSN (HOW VERIFIED?)

10. RESIDENCY:

11. STUDENT STATUS (EXPLAIN ELIGIBILITY):

12. EARNED INCOME (ACTUAL/ANTICIPATED & HOW VERIFIED?)

13. WAGE:

14. DPPL:

15. HINQ/SSNX:

16. UNEARNED INCOME (ACTUAL/ANTICIPATED & HOW VERIFIED?)

17. ECLM:

18. SMUX/SMR1:

19. DOR MONTH FOR MEDICAL IS:

20. GROSS INCOME FOR BUDGET MONTH:

21. GROSS INCOME FOR LAST MONTH:

22. GROSS INCOME FOR 2 MONTHS AGO:

23. GROSS INCOME FOR 3 MONTHS AGO:

24. 3-MONTH AVERAGE:

25. IF ZERO INCOME, HOW MEETING BASIC NEEDS (OHP7219):

26. RESOURCES:

27. DEPRIVATION (BASIS FOR MAA):

28. ABSENT PARENTS:

29. 12-MONTH JOB QUIT FOR TANF/MAA (2 - parent household) (GOOD cAUSE?):

30. DISABILITY (NEED ACCOMMODATION?):

31. CHILD WELFARE INVOLVEMENT:

32. HEALTH INSURANCE (PLANS CHOSEN; TPR; HNA):

33. REFERRALS ( FHIAP, PRESUMPTIVE MEDICAL):

34. APPLICATION SIGNED, DATED AND IN FILE?

35. ELIGIBILITY DECISION/CERT PERIOD:

36. MAA/MAF:

37. OHP:

38. OTHER MEDICAL PROGRAM:

39. DOES INCOME REPORTED DIFFER FROM CURRENT FOOD STAMP

CALCULATIONS?:

40. DENIAL NOTICES: (462A? 426C? Close Notice?)

41. PENDED FOR?

42. ADDITIONAL COMMENTS:

5503 Children's Medical Project - FACILITY PLACEMENT

Worker:

Case #:

Program:

Date of placement:

Comments:

Facility Name:

If Contract #:

If Contract #, list MHO status:

If ELGF:

Estimated length of stay:

Review due:

If WQY2:

If SMUX/SMR1:

If TPR (415h sent to HIG?):

Plans:

If HMU Template sent, delete the one that doesn’t apply:

Out of Area Exception and duration:

Request for Exemption and duration:

Date sent:

(Note: this date should coincide with ELGX)

Citizenship/Identity established.

If yes how?

5503 Children's Medical Project - STATUS CHANGE / CLOSURE

Worker:

Case#:

Program:

Date of placement:

Comments:

Facility:

Status change notification received:

Date released:

Placed at:

If Contract #:

If ELGF:

If estimated length of stay:

If recert due:

If WQY2:

If SMUX/SMR1:

If TPR (415h sent to HIG?):

Plans:

IF HMU Template sent, delete the one that doesn’t apply.

Out of Area Exception end date:

Request for Exemption end date:

Due Process:

Request for application sent to OSCI?

45 day limit:

If open SSP case, branch contacted?

IF Notice(s) sent, delete any that don’t apply.

GSMCHGN: CMP; Notification of Address Change

GSMAPPM: Notify App Mailed

5503 Children’s Medical Project - DD / MFC

Worker:

Case #:

Program:

DOR:

Review Date:

Comments:

Does SL01 c/d coding match application?:

Coding entered on UCMS as requested?:

WQY2:

Amount:

Plans:

If TPR (415H sent to HIG?):

Note: DD children exempt from Citizenship/Identity requirements.

5503 Children's Medical Project - ELIGibility REVIEW

Worker:

Case#:

Program:

Comments:

Address/Phone:

If WQY2:

If SMUX/SMR1:

If TPR (415H sent to HIG?):

Plans:

Next review due:

5503 Children's Medical Project - SREL/ SAC

Worker:

Case#:

Program:

SAC or SREL:

Date of placement:

Review due:

Comments:

If WQY2:

If SMUX/SMR1:

If TPR (415h sent to HIG?):

Plans:

Note: Title IV-E children exempt from Citizenship/Identity requirements.

5503 Children's Medical Project – SREL Eligibility Review

Worker:

Case#:

Program:

Check any screens that apply.

WQY2:

SMUX/SMR1:

ELGR:

ELGX/T:

FACIS:

B Screen:

ELGF:

Comments:

Address/Phone:

Plans:

Next review due:

Citizenship/Identity established. If yes, how?

OHP - 5503 ***BCCP APPROVEd***PEND CITIZEN / IDENTITY**

WORKER ID:

CASE #:

DATE OF REQUEST:

DATE RECEIVED / FAXED DATE:

MEDICAL START DATE (QUALIFICATION DATE):

NUMBER OF MONTHS client NEEDs TREATMENT:

RECEIVED INITIAL REQUEST FOR BCCP / WAITING FOR CITIZENSHIP / IDENTITY RESPONSE

Pend DUE date:

next rev date:

SENT CITIZENSHIP/ IDENTITY LETTER

OHP - 5503 ***BCCP APPROVEd***PEND CITIZEN / IDENTITY**

WORKER/ID:

CASE #:

DATE OF REQUEST:

DATE RECEIVED / FAXED DATE:

MEDICAL START DATE (QUALIFICATION DATE):

NUMBER OF MONTHS NEED TREATMENT:

RECEIVED INITIAL REQUEST FOR BCCP / WAITING FOR CITIZENSHIP / IDENTITY RESPONSE

Pend DUE date:

next review DATE:

SENT CITIZENSHIP/ IDENTITY LETTER AND 45 DAY APPROVAL TODAY

OHP - 5503 *****BCCP NEW**APPROVED***

WORKER / ID:

CASE # :

DATE OF REQUEST :

DATE RECEIVED / FAXED DATE :

MEDICAL START DATE (qualification date):

NUMBER OF MONTHS NEED TREATMENT:

HAS BENEFITS THROUGH:

NEXT REVIEW date:

COMMENTs:

ohp-5503 *******BCcP close at redetermination**************

WORKER ID:

DID NOT RECEIVE REDETERMINATION:

MEDICAL WILL END:

ohp-5503 ***BcCP***REDETERMINATION APPROVED***

WORKER/ID:

CASE #:

MEDICAL START DATE (QUALIFICATION DATE):

NUMBER OF MONTHS NEED TREATMENT:

NEXT REVIEW DATE:

Sent letter of approval

OHP - 5503 *****BCCP REDETERMINATION*****

WORKER/ID:

CASE #:

SENT REDETERMINATION PAPERS AND REMINDER NOTE TO CLIENT (establishes DOR for redetermination):

pend DUE date:

OHP - 5503 *** SENIOR PRESCRIPTION DRUG PROGRAM - APPROVED ***

PROGRAM ENROLLMENT

WORKER ID:

CASE #:

CLIENT:

COMMENTS:

A/R has paid SPDAP program fee, based on Earhart report on View Direct. Updated UCMS and CMUP to reflect program membership start on benefits thru .

This is a discount program, not Rx insurance coverage for client.

OHP - 5503 *** SENIOR PRESCRIPTION DRUG PROGRAM – APPROVE/PEND FOR PROGRAM FEE ***

WORKER ID:

CASE #:

APPLICANT:

RESOURCES:

INCOME - MONTHLY: $

INCOME - ANNUAL: $

SPEAK:

WRITE:

ALTERNATIVE FORMAT:

AUTHORIZATION TO RELEASE:

RELATIONSHIP:

PHONE:

COMMENTS: Approved Senior Rx program. Awaiting notification of $50 enrollment fee received. Under 185% FPL; meets criteria. This is a discount program, not Rx insurance coverage.

PEND DUE DATE:

OHP - 5503 *** SENIOR PRESCRIPTION DRUG PROGRAM - CLOSURE***

CASE CLOSURE, ORS 414.340; OAR 461-135-1180, 461-175-0200 (1)(a), 461-115-0190 (1)

WORKER ID:

CASE #:

CLIENT:

ALTERNATIVE FORMAT:

AUTHORIZATION:

CLOSED EFFECTIVE:

COMMENTS:

[ ] Client and billing agency have been informed of closure and request for refund.

Client now receiving prescription drug insurance through:

[ ] Private insurance

[ ] State program

OHP - 5503 *** SENIOR PRESCRIPTION DRUG PROGRAM – CLOSURE – Version 2***

CASE CLOSURE, ORS 414.340; OAR 461-135-1180, 461-175-0200 (1)(a), 461-115-0190 (1)

WORKER ID:

CASE #:

CLIENT:

NO ENROLLMENT FEE RECEIVED; MAY REAPPLY ANYTIME

COMMENTS: Client approved for program; Fee not paid. Pend codes dropped off by system. NOTM CMDSANN sent to client today.

OHP - 5503 *** SENIOR PRESCRIPTION DRUG PROGRAM - DENIAL***

DENIED, ORS 414.340; OAR 461-135-1180, 461-175-0200 (1)(a), 461-115-0190 (1)

WORKER ID:

CASE #:

CLIENT:

ALTERNATIVE FORMAT:

AUTHORIZATION RELEASE:

COMMENTS: System notice sent to client.

5503 *** SENIOR PRESCRIPTION DRUG PROGRAM - PEND ***

PEND NOTICE, ORS 414.340; OAR 461-135-1180, 461-175-0200 (1)(a), 461-115-0190 (1);

WORKER ID:

CASE #:

CLIENT:

ALTERNATIVE FORMAT:

AUTHORIZATION:

COMMENTS:

OHP- 5503 *****BED DATE ADDED-BENEFITS RESTORED*****

WORKER ID:

CASE #:

DOR:

BED DATE:

ACTION ON UCMS:

OHP-5503 *****BYPASS end date APP Created*****

WORKER ID:

CASE #:

DOR:

BED DATE:

Date BED app created:

ACTION ON UCMS:

OHP 5503 *****BYPASS END DATE REAPP RECEIVED*****

WORKER ID:

CASE #:

BED DATE:

DATE REAPP RECEIVED:

ACTION ON UCMS:

OHP 5503 *****BYPASS END DATE PHONE CONTACT*****

WORKER ID:

CASE #:

NAME OF PERSON CALLING:

BED DATE:

HAS AN APPLICATION BEEN SENT IN (Y/N)?

WHEN WOULD BE THE BEST TIME FOR A WORKER TO CALL IF THEY HAVE QUESTIONS?

COMMENTS:

OHP - 5503 ***PREGNANCY NOTIFICATION***

WORKER ID:

CASE#:

PREGNANCY NOTIFICATION RECEIVED FROM PROVIDER FOR:

DUE DATE:

FA OF UB NEEDED FOR OHP MEDICAL

OHP - 5503 ***NOTIFICATION TO BRANCH OF PREGNANCY***

5503 WORKER ID:

CASE#:

ROUTE TO BRANCH #:

BRANCH WORKER:

PREGNANCY NOTIFICATION RECEIVED FROM PROVIDER FOR:

DUE DATE:

FA OF UB NEEDED FOR OHP MEDICAL

WE ARE UNABLE TO ADD UNBORN TO SPD, MAA, EXT, M5, OR COMPANION CASES. WE ARE ROUTING THIS NARRATIVE TO THE CORRECT BRANCH TO ADD PREGNANCY.

OHP - 5503 ***NOTIFICATION OF PREGNANCY LOSS/TERMINATION***

WORKER ID:

CASE#:

ORIGINAL DUE DATE:

DATE OF CLAIM/SERVICE:

A/R'S MEDICAL ENDS:

DATE NOTICE SENT:

OHP - 5503 ***NOTIFICATION TO BRANCH OF PREGNANCY LOSS/TERMINATION***

5503 WORKER ID:

CASE#:

ROUTE TO BRANCH #:

BRANCH WORKER:

ORIGINAL DUE DATE:

DATE OF CLAIM/SERVICE:

WE ARE UNABLE TO REMOVE THE UNBORN ON SPD, MAA, EXT, M5, OR COMPANION CASES. WE ARE ROUTING THIS NARRATIVE TO THE CORRECT BRANCH TO REMOVE UNBORN.

OHP - 5503 *** NEWBORN ADDED TO CASE ***

WORKER/ID:

CASE #:

CLIENT OR MEDICAL PROVIDER NOTIFIED US OF THE BIRTH OF A CHILD.

BABY NAME:

DOB:

FATHER:

SEX OF BABY:

MEDICAL/DENTAL PLANS CHOSEN:

COMMENTS:

OHP - 5503 *** NOTIFICATION TO BRANCH OF NEWBORN ***

5503 WORKER/ID:

CASE #:

ROUTE TO BRANCH #:

BRANCH WORKER:

THE CLIENT OR MEDICAL PROVIDER NOTIFIED US OF THE BIRTH OF A CHILD. WE ARE UNABLE TO ADD NEWBORN TO SPD, MAA, EXT, M5, OR COMPANION CASES. WE ARE ROUTING THIS NARRATIVE TO THE FIELD BRANCH TO MAKE THE NECESSARY CHANGES.

BABY NAME:

DOB:

FATHER:

SEX OF BABY:

MEDICAL/DENTAL PLANS CHOSEN:

COMMENTS:

OHP - 5503 ***UF / AF REPORT CHANGE***

5503 WORKER ID:

CASE NUMBER:

Case updated with the following information:

Name of child:

Name of Father:

Status (AF/FA):

Verification source:

Comments:

OHP - 5503 ***NOTIFICATION TO BRANCH OF UF-FA REPORT CHANGE***

5503 WORKER ID:

CASE NUMBER:

ROUTE TO BRANCH #:

BRANCH WORKER:

We are routing this notification to the correct branch because we are unable to update paternal information ON SPD, MAA, EXT, M5, OR COMPANION CASES.

Please update the case with the following information:

Name of child:

Name of Father:

Status (AF/FA):

Verification source:

Comments:

OHP-5503 *** DCS SANCTION APPLIED ***

CASE#:

WORKER ID:

COMMENTS:

OHP – 5503 ***CHANGE TO CASE***

WORKER ID:

CASE #:

PER DMAP REPORT THIS CLIENT IS HNA ELIGIBLE

PLACED HNA CODING ON PRIME NUMBER:

WILL DISENROLL FROM PLANS AND PLACE EXEMPT CODING ON CASE THE NEXT WORKING DAY.

OHP - 5503 ***CHANGE OF ADDRESS***

WORKER ID:

CASE#:

ADDRESS CHANGED ON UCMS

NEW ADDRESS:

OHP - 5503 ***NOTIFICATION TO BRANCH OF ADDRESS CHANGE***

WORKER ID:

CASE#:

ROUTE TO BRANCH #:

BRANCH WORKER:

CLIENT NOTIFIED US OF AN ADDRESS CHANGE. WE ARE UNABLE TO CHANGE ADDRESSES ON SPD, MAA, EXT OR COMPANION CASES. WE ARE ROUTING THIS NARRATIVE TO THE CORRECT BRANCH TO MAKE THE ADDRESS CHANGES.

NEW ADDRESS:

OHP- 5503 *** OHP REOPEN/RESTORE MEDICAL***

NAME / WORKER ID:

CASE:

REASON:

OHP - 5503 ***UNABLE TO RESTORE DU CLOSED CASE***

WORKER ID:

CASE#:

DATE CASE DU CLOSED:

DATE CLIENT CALLED:

REASON CASE CANNOT BE RESTORED: Client did not request restoration within timelines established by policy. (ADM: 461-175-0210)

OHP - 5503 ***148 SENT***

WORKER ID:

148 FOR WHOM:

CASE NUMBER:

AFS 148 SENT TO CLIENT MAINTENANCE

REASON:

OHP - 5503 **HEALTH INSURANCE PREMIUM REIMBURSEMENT (HIP) **

WORKER ID:

CASE #:

HIP PAYMENT AMOUNT:

DATE PAYMENT SENT:

PAY PERIOD:

OHP-5503 ***OHP CLIENT HAS OR IS ELIGIBLE FOR MEDICARE - CLOSURE***

WORKER ID:

CASE #:

OHP MEDICAL CLOSED:

DATE NOTICE SENT:

RECEIVED INFORMATION THAT A/R HAS MEDICARE SINCE:

MEDICARE STARTING:

OHP - 5503 ***CHIP WITH TPR CLOSURE***

WORKER:

CASE #:

RECEIVED NOTIFICATION CHILDREN CHIP ELIGIBLE WITH TPR

CLOSED CASE/CHILD(REN) EFFECTIVE:

NOTICE SENT THIS DATE:

HIP RECEIVED:

AMOUNT: $

HIP CLOSURE NOTICE SENT:

COMMENTS:

OHP - 5503 ***CWM no CHIP CLOSURE***

WORKER:

ALTERNATE FORMAT:

CASE #:

RECEIVED NOTIFICATION CHILDREN CHIP ELIGIBLE THAT ARE CWM

CLOSED CASE/CHILD(REN) EFFECTIVE:

NOTICE SENT THIS DATE:

HIP RECEIVED:

AMOUNT: $

HIP CLOSURE NOTICE SENT:

COMMENTS:

OHP - 5503 ***MEDICAL CASE CLOSED PER CLIENT REQUEST***

WORKER ID:

CASE #:

PER REQUEST FROM CLIENT, CLOSED CASE EFFECTIVE:

COMMENTS:

OHP - 5503 ***CASE TRANSFER***

WORKER #:

CASE #:

TRANSFERRED TO BRANCH #:

TO WORKER:

COMMENTS:

OHP - 5503 *** COMPANION CASE TRANSFER ***

5503 WORKER ID:

CASE#:

TRANSFERRED ON LINE TO BRANCH:

WORKER ID:

REASON:

OHP - 5503 ***FS COMPANION CASE TRANSFER***

WORKER ID:

CASE#:

TRANSFERRED ON LINE TO BRANCH #:

BRANCH WORKER:

REASON: COMPANION FS CASE

OHP-5503 ***5503 MEDICAL TRANSPORTATION***

WORKER/ID:

Amount Sent:

Date Sent:

Date Requested:

Date of Appointments:

What They're Requesting:

OHP – 5503 ***415H SENT TO CLIENT***

WORKER ID:

CASE NUMBER:

AFS415H SENT TO CLIENT

COMMENT:

OHP – 5503 ***HEARING REQUEST SENT TO CLIENT***

WORKER ID:

CASE NUMBER:

HEARING REQUEST SENT TO CLIENT.

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