Agenda - 11-19-1991 - Laserfiche WebLink

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32 PURPOSE OF FORM: This form is to be used to rotor a client to the DSS for authorization to provide %orvicos, and for county DSS's 10 transmit to providers the authorization and the dole rtoceswry to claim reimbur►ement. SECTION 1: (To be completed by the referring agency if the form is initiated by someone other than the DSS.) Specify the regvested service($) and the agency to be providing the service(%). 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 agency or the county DSS.) If h is completed by the referring agency, the DSS should compere the information with their records for accuracy of name, address, and birthdote. SECTION 111: (To be completed by the DSS only,) line A. Indicate whether the provider is er is not authorized, to provide services under Title XX by circling (is) or (is not), (IF THE PROVIDER IS NOT AUTHORIZED, DO NOT COMPLETE 111 9, IV, OR V.) Line B: Specify the time period for which service(%) 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 outhorizoton if client situation changes before the end of an existing period of authorization, SECTION IV: (To be completed 6y the DSS only,) Item A: Enter the cede for the authorized service(%) or component of the discrete service in accordance with the service codes reflected on 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 a change in the amount of a fee during on established period of authorization. The effective date line con be left blank If the efiev—e cote el the fee is the so—e as the benir -ng deter of The pence of ovthorizotion. Item, 6 If Child Day Cc-e Services are authorized in Item A of this Section, indicate whether supplementol needs services ore or ore not authorized for reirtibursen.eni at the supplemental needs payment rate by circling (are) or (ore 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 00i— Cvrrent Recipient of SSI —Aged 'Code 002 — Current Recipient of 551—Blind 'Code 005— Current Recipient of SSI -- Disabled 'Code 005— Currottt Recipient of AFDC 'Code 007 — Medicaid Only-- Recioienn `Code 013 —WIN Elrpibie "Code 009 — Income Eligible with Less than 60% of Established Income "Code 010 -- Income Eiigibie with 60 96-79% of Establisned Income "Code 011 — Income Eligible with 80% -100% Of Established Income "•Code 012 — Without Regard to Income "'Cone 01a —Child Weliare Services "•Code 019— without Regard to Income -- Adjustment Services for the Blind and Visually Impaired, Adoption Services, Foster Core Services for Adults, Faster Care Services for Children For purposes of the 50 Percent Rule: *indicates individuals who are in income maintenance and relared status "indicates individuals who are in family income status "'is not considered in calculating compliance Line B: Enter the ID N of the recipient for whom this service is authorized. Enter the name of the DSS, the name of the service warner completing the farm and the telephone number of the service worker. The farm is to be signed by an authorised representative of he county.bM Enter the date on which the form was signed. The County Identifier and County Case it lines are optianai and may be used by the emmy to fodfitate distribution or filing within the agency. If the county oats to use the County Case 9, the provider must use the number when corresponding with the county about this porticvlor client. b:STPJWT10k: Complete in ciupiicatit. One copy for service record and am copy far provider ogencrr. DSS -1360 (Rev. 7/F5; Family Services