Agenda - 11-19-1991 - Laserfiche WebLink

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PURPOSE OF FORM: This form is to be used to rotor a client to the DSS for authorization to provide services, and for County DSS's to transmit to providers the authorization and the data necessary to chins reimbursement. SECTION I: (To be completed by the referring agency if the form is initiated by someone other than the DSS.) Specify the requested service(s) and the agency to be providing the service(:), Indicate the person making the referral and the agency he represents. The agency making the referral may be the provider agency. SECTION 11; (To be completed by the initiator of the form, whether it is the referring agency or the county DSS.) If it is completed by the referring agency, the DSS should compare the information with their records for accuracy of name, address, and birthdate. , 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 1118, IV, OR V.) Line B: Specify the time period for which service(s) is authorized, line C: Enter the Purchase Program ID St. 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 outhorizoton 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 services) or component of the discrete service in accordance with the service codes reflected an the client's service plan (DSS - 2515/2516). If fees are 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 date 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 a fee during an established period of authorization. The effective date line can be left blank if the effective dote of the fee is the some as the beginning date of the period of oulhorizotion. hem B: if Child Day Co-e Services are authorized in Item A of this Section, indicate whether supplemental needs services are or are not authorized for reimbursement at the supplemental needs payment rote by circling (ore) or (are not) SECTION V: (To be completed by the DSS only.) Designate the recipient category reflected on the client's service plan (DSS- 2515/2516). "Code 001-- Current Recipient of SSI —Aged *Cod* 002— Current Recipient of SSI - -Blind 'Code 003— Current Recipient of SSI— Disobled "Code 005— CurroM Recipient of AFDC 'Code D07— Medicaid 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 80% --100% Of Established Income ***Code 012 — Without Regard to.lncome • Code Ole —Child Welfare Services "Code 019 — Without Regard to Income— Adiustmeni Services for the Blind and Visually Impaired, Adoption Services, Faster Care Services for Adults, Foster Care Services for Children For purposes of the 50 Percent Rule: 'indicates individuals who are in income maintenance and related status ••indicates individuals who are in family income status `is not considered in calculating compliance Line B: Enter the ID N of the red0iont for whom this service is authorized. Enter the name of the DSS, the name of the service worliei Completing the form and the telephone number of the service worker. The form is to be signed by an authorized representative of the county. DSS. Enter the date on which the form was signed. The County Identifier and County Case ft lines are optional and may be used by the County to facilitate distribution or filing whhin the agency. If the county opts to use the County Case 0, the provider must use the number when corresponding with the county about this porliesdar dient. DISTRIBUTION: Complete in duplicate. One copy for service record and am copy for provider agency- DSS-1360 (Rev. 7/85) Family Services