Agenda - 08-17-1993 - VIII-F - Laserfiche WebLink

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29 •JRPOSE OF FORM: This form is to be used to reter o client to the D55 for out horizaton to provide services, and for county DS5's to transmit to providers the authorization and the data necessary to claim r•imbvrsem.M. SECTION I: (To be completed by the referring ogency if the form is initiated by someone other than the DSS.)Specify the requested service(s)and the ogency to be providing the service(s). Indicate the person making the referral and the agency he represents. The agency moking the referral may be the provider agency. SECTION II: (To be completed by the initiator of the form, whether it is the referring ogency or the county D55.) If it is completed by the ref erring agency, the D55 should compare the information with their records for accuracy of Home, address, and birthdote. , SECTION III: (To be completed by the DSS only.)Line A. Indicate whether the provider is or is not authorized,to provide services under Title XX by circling(is)or(is not). (IF THE PROVIDER IS NOT AUTHORIZED, DO NOT COMPLETE Ill B, IV,OR V.) Line B: Specify the time period for which service(s) is authorized. Line C: Enter the Purchase Program ID R. If the form is initiated by the provider agency, they may enter this number to facilitate processing. Line D: Enter the date of termination of authorizoton if client situation changes before the end of on existing period of authorization. SECTION IV: (To be completed by the DSS only.)Item A: Enter the code for the authorized service(s)or component of the discrete service in occordonce with the service codes reflected on the client's service plan (DSS•2515/2516). If fees ore applicable specify the fee to be imposed for the service, the unit of service to which the fee applies, e.g., per task, per client, per hour, etc. Enter the dote the provider is to begin imposing the fee if the form is being used to inform the provider of o change in the amount of o fee during on established period of authorization.The effective dote line con be left blank if the efiecr, a dote cf the fee is the some as the beainr.■ng dote of the period of authorization, Item E If Child Doy Cc•e -- Services ore authorized in Item A of this Section, indicate whether supplemental needs services are or ore not authorized for reimbursement of the supplemental needs payment rate by circling (ore)or (ore not) SECTION V: (To be completed by the DSS only.) Designate the recipient category reflected on the client's service plop (DSS•2515/2516). •Code 001—Current Recipient of SSI—Aged 'Code 002—Current Recipient of 551—Blind •Code 003—Current Recipient of 551—Disabled 'Code 005—Current Recipient of AFDC •Code 007—Medicoid Only—Recipients 'Code 013—WIN Eligible "Code 009—Income Eligible with Less than 60% of Established Income "Code 010—Income Eligible with 60%-79% of Established Income • "Code 011—Income Eligible with B0%-100%Of Established Income ••'Code 012—Without Regard to Income •••Code 014—Child Welfare Services •"Code 019—Without Regard to Income—Adjustment Services for the Blind and Visually Impaired, Adoption Services, Foster Care Services for Adults, Foster Care Services l'eir Children For purposes of the 50 Percent Rule: •indicates individuals who ore in income maintenance and related status , _ • "indicates individuals who ore in family income status •'•ts not considered in calculating compliance Line B: Enter the ID K of the recipient for whom this service is authorized. • Enter the name of the DSS, the name of the service worker'completing the form and the telephone number of the service worker. The form is to be signed by on authorized representative of the county.DSS. Enter the dame on which the form was signed. The County Identifier and County Cos.x lines ore optionol and may be used by the county to facilitate distribution or filing within the ogency. if th•county opts to use the County Case N,the provider must use the number when corresponding with the county about this particular diem. DISTPJBUTION: Complete in duplicate. One copy for service record and one copy for provider agency. DSS•1360(Rev. 7/85) Family Services