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:
- Systematic Alien Verification of Entitlements (SAVE) confirmation;
- Birth certificate or acceptable alternative;
- Social Security card or verification;
- Marriage/divorce decrees;
- Death certificates;
- Insurance cards;
- Passports;
- Copies of identification (ID) documents;
- Guardianship documents;
- Adoption records;
- Other legal documents.
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 |
Application related forms not specified elsewhere |
SDS 540 |
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
- Vehicle titles;
- Property statements/settlements;
- Insurance policies;
- Statement from financial institutions;
- Statement of abuse;
- Rental contracts.
SECTION 4 - FINANCIAL
Forms:
DHS 859B |
Self-Employment Income |
DHS 943 |
Change Report |
DHS 7351 |
Educational Income Calculation for ERDC and SNAP |
MSC 221 |
SNAP eligibility computations |
MSC 284 |
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:
- Wage match reports;
- Income such as: Unemployment Compensation, lottery winnings, Workers' Compensation, pay checks, etc.
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:
- Medical/Dental reports;
- Office of Vocational Rehabilitation (OVRS) documents;
- Mental Health and Developmental Disability Services Division (MHDDSD) documents or statements;
- Medical/dental bills or receipts.
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 |