V.B Filing in the Master Case Record

7/8/13

The APD Worker Guide G.5 gives specific filing information, but does not include specific forms. Below is a guideline for forms and documents commonly used by APD.

SECTION 1 - VITAL STATISTICS

Verification of vital statistics such as citizenship and Social Security number:

SECTION 2 - APPLICATIONS

Applications for all benefits including ongoing medical; do not print and file applications received from the online eligibility application. Include all applications used by other programs in files transferred to the local office. Applications for benefits not mentioned below will also be filed in this section.

DHS 415Y

Re-Application for Food Stamp Benefits

DHS 7470

Application for Employment Related Day Care Program

DHS 7476

Employment Related Day Care Re-Application and Food Stamp Application

MSC 210M

Notice of Pending Status on Medical Application

MSC 415F

Application for Services

OHP 7210

Application for Oregon Health Plan and Healthy Kids

SDS 539A

Application

SDS 539C

Medicaid Redetermination/Medicare Savings Program Application

 

SECTION 3 - DOCUMENTATION/VERIFICATION

Materials used to verify the eligibility of customers for benefits.

DHS 852

Interim Change Report for SNAP and ERDC

DHS 1058

Declaration of Indigency

MSC 148

Request for Retroactive Eligibility

MSC 231

Designation of Authorized Representative or Alternate Payee

MSC 371

OPAR Fraud Investigation Unit Referral

MSC 451

Vehicle Related Personal Injury

MSC 451NV

Non-Vehicle Related Personal Injury

MSC 647

Real and Personal Property

MSC 2099

Authorization for Use and Disclosure of Information

OHP 7207

Coordinated Care Organization Transition Checklist and Referral

OHP 7210

Application for the Oregon Health Plan and Healthy Kids

SDS 245

Authorization for Office Issuance of an Oregon Trail Card

SDS 539
 series

Application related forms not specified elsewhere

SDS 540
 series

Notifications not specified elsewhere

SDS 541

Notice of Eligibility and Responsibility

SDS 728

MMA Problem Solving Referral Form

SDS 1219HE

Verification of Housing Expenses

 

Other documents

SECTION 4 - FINANCIAL

Forms:

DHS 859B

Self-Employment Income

DHS 943

Change Report

DHS 7351

Educational Income Calculation for ERDC and SNAP

MSC 221
 series

SNAP eligibility computations

MSC 284
 series

Overpayment related forms

MSC 437

Authorization of Cash Payment

MSC 454D

Report on Deceased Persons

MSC 851

Verification of Earnings (only if discrepancy)

MSC 1295

SNAP Claim Data Sheet

SDS 195

Trust Agreement for Limited Account

SDS 198

Trust and Agency Action (Authorization of Payment)

SDS 450

Liability Worksheet for Long Term Care or Waivered Services

SDS 543

Information on Transfer of Assets Penalties

SDS 545

Notice of Beneficiary Assignment

SDS 905

Notification of Case Transfer

SDS 3401

Resource Assessment

SDS 3401A

Allocating Resources to Generate Income for a Community Spouse

SDS 3402

Notification of Allowances

SDS 3403

Notification of Excess Resources

 

Other documents:

SECTION 5 - MEDICAL

Medical records, private health insurance information, medical expenses:

DHS 409A

Schedule of Appointments

DMAP 405T

Medical Transportation Order

DMAP 409

Medical Transportation Screening/Input Document

DMAP 729 series

Administrative Medical Examination/Report Authorization

MSC 415H

Notification of Other Insurance

OHP 7208M

Medicare Choice Election Form

OHP 7209

Request to Terminate Insurance

SDS 415D

Retroactive Medical Supplement

SDS 620

Request for Presumptive Medicaid Disability Decision

SDS 704R

GA Medical Review Team Worksheet

SDS 708

Disability Referral

SDS 1238B

List of Medical Expenses

 

Other documents:

SECTION 6 - SERVICES

Forms and materials related specifically to eligibility for services:

SDS 001

Client Plan Form

SDS 002

Assessment Summary Form

SDS 003

Client Details

SDS 354

Worker's Compensation Agreement and Consent

SDS 458A

Financial Planning Title XIX

SDS 460

Level I Pre-Admission Screening for MR/DD/SMI

SDS 461

Private Admission Assessment

SDS 514

Request for Exception

SDS 546

In-Home Care Plan

SDS 546D

Adult Day Services – Payment Authorization

SDS 546IC

Independent Choices Benefit Calculation

SDS 541N

In-Home Service Plan - New

SDS 546N

State Plan Personal Care – Service Plan and Task List

SDS 546SF

Service Plan Short Form

SDS 547

Notice of Payment Responsibility

SDS 546W

Multiple In-Home Provider Worksheet

SDS 595

Authorization and Provider Invoice for Home Delivered Meals

SDS 598

Task List

SDS 737 

Client-Employed Provider Program Participation Agreement

SDS 914

Client Choice of Service Options

SDS 4102

Prior Authorization for APD Long Term Care Community Nursing

SDS 4105

Homecare Worker Notice of Authorized Hours and Services