Katie Beckett Packet - Forsyth County Schools Beckett...DKatie Beckett . Were you in foster care on...

Please return applicatio~ either to the local DFCS Office or return directly to the address below

Right from the Start Medicaid Project Centralized Katie Beckett Medicaid Team 5815 Live Oak Parkway Suite 2~0 Norcross GA 30093

If you have any questions please contact us

678-248-7449 (phone) 678-248-7459 (fax)

We will consider this application without regard to race FOR COUNTY USE ONLYMEDICAID APPLICATION color sex age disability religion national origin or Date Received in County Dept political belief D Pregnant Woman D Families wChildren - LIM

Check block(s) that D Child(ren) Only- RSM D Chafee Independence Program Medicaid

apply to you DKatie Beckett Were you in foster care on your 18th birthday D Yes D No In which state __

PLEASE NOTE A Face to Face interview is not required for Medicaid applications Please answer all questions as completely and accurately as possible Ifyou cannot understand or complete this application Please notitv lJtCS start and assistance will be provided free of charge

Your Name (Please Print) FIRST MI Last Maiden (if applicable) Todays Date

Mailing Address City State IZip Code

Residence Address (if different from Mailing Address) Phone Number(s) E-mail Address

Please list all persons living with vou for whom vou want Medicaid List vourself if vou want Medicaid for vourself

Is this Person a

US Does the Citizen Father of Does the (YIN)

this child Mother of(you may live in this child qualify for

Medicaid your live in your Suffix Sex Social Security even if you home home

First Name MI Last Name (Jr) Race MIF Date ofBirth Relationship to You Number answer No) (YIN) (YIN)

Please list all persons living with you for whom you DONT want Medicaid List yourself ifyou dont want Medicaid You do not have to provide a SSN or immigration status information for any person who is not asking for Medicaid If provided we will use the SSN for computer matches with other agencies and it may help us process your childs application We will NOT share your

--- --- middot-middot-------- -1 ---shy

Is anyone in the household pregnant D Yes D No Ifyes who is pregnant ___________ Due Date _____ _ Please attach verification of pregnancy if available Do you have any unpaid medical bills from the past three months D Yes O No Ifyes which months ___ _______ __________________

Does anyone in your household have Health Insurance D Yes D No If yes list Insurance Company and policy number

Have you or anyone in your household been diagnosed with Breast or Cervical Cancer D Yes D No Ifyes have you received Womens Health Medicaid previously D Yes O No

Form 94 (1110)

lNCOME RESOURCES and DEPENDENT CARE List all income received by persons on page 1 of this application Be sure to show the amount before deductions Attach an extra sheet if necessary We will decide based on the type ofMedicaid whose income must oe counteo ano wnose mav oe exc1uoeo u vou are ann1v1n2 tor Lnuaren univ or Yre2nant woman Meatcata vou ao not nave to complete tbe KesourcesVebicles sections below

Income

WagesEarnings

Current Employer

WagesEarnings

Gross Amount per Pay Check

(amount before deductions)

How Often (weekly every 2-weeks

monthlv etc) Name of Person Receivin2

~0middot1 r~

Pyeni~-shy ~ fill ~middotIbull

1raquo4 lt~qr gt~ ~ j 1middot

Resources

Cash

Checkine Account

Savings Account

Amount in AccountNalue

Who Owns Resource

Current Employer ~ shy l Credit Union

Social Security lncomeSSI

- 401KRetirement~)~ Account

Workers Compensation

-~~centbull Other Pensions or bull_ middot Vehicle(s) Cars trucks motorcycles (licensed)Retirement Benefits

middot~bull r

Child Support Amount bull Make Model Year

Contributions -- Owed middot~ Unemployment ~shyBenefits middot~ -Other Income please bullmiddot

specify tgt )o you pay for~ependent care (daycare for a child or care for an adult who cannot care for himselfherself) so that someone in your household can work

How Often (weekly 2-weeks Name of child or adult cared for Name ofcare provider Amount of Payment monthly etcName of Parent who works

ff you are applying children and one orlying forfor MedicaidMedicaid forfor childr 1d bothofth middotr parents are not middot the h dome please provide the followmg information Do they have Medical Coverage on the Child IfYes to Medical Coverage please list name

Childs Name Absent Parents Name ltMotherFather) YesNo of insurance company amp 2roup number

understand that this information may need to be verified to determine eligibility I understand wage and salary information supplied by the Georgia Department ofLabor may be obtained to erify and determine eligibility for Medicaid I agree to assign to the state all rights to medical support and third party support payments (hospital and medical benefits) I agree to give the tate the right to require an absent parent provide medical insurance if available I understand I must get medical support from the absent parent ifit is available and must cooperate with the )ivision ofChild Support Services in obtaining this support IfI do not cooperate I understand I may lose my Medicaid benefits and only my children will receive benefits unless good ause is established I understand that I must report changes in my income and circumstances within ten (10) days ofbecoming aware ofthe change J I certify under penalty ofperjury that I am a US Citizen andor lawfully present in the United States Ifl am a parent or legal guardian I certify that the applicant(s) is a US Citizen mdor lawfully present in the United States 0 I certify to the best of my knowledge and belief that the person(s) for whom I am applying for Medicaid isare US citizen(s) or are lawfully resent in the United States I further certify that all of the information provided on this application is true and correct to the best of my knowledge

Date ________ ____ _ _ Hgnature (Required) -------------------------------- shy

orm 94 (1110)

- -- --

DECLARATION OF CITIZENSIDPIMMIGRATION STATUS I understand that the Ga Division of Family and Children Services may require verification from the United States Department of Homeland Security ofmymy childrens citizenship or immigration status when seeking benefits Information received from DHS may affect mymy childrens eligibility

Please fill out and sign ONE or BOTH ofthe following statements as it pertains to the status of each person seeking benefits

CHILDREN SEEKING BENEFITS

US Lawfully Date Naturalized Citizen Admitted or Admitted into US

Immigrant -- --- ----J ------ -JI -ll--ft fYl1110ll1Y~I auubull1ic1 U aumnameJ

I _ _ _________ attest to the identity of the childchildren listed above and (PRINT NAME)

certify under penalty ofperjury that the information written and checked above is true

SIGNATURE (PARENTGUARDIAN) (DATE)

ADUL T(S SEEKING BENEFITS


1~ame ltace ot Hirth (citystatecountrvl Immigrant

(Check whichever applies) (If applicable)

I _________________ (PRINT NAME)

SIGNATURE (PARENTGUARDIAN)


__ certify under penalty ofperjury that the information written and checked above is true

(DATE)

(DATE)

Form 94 (1110)

Notice of Privacy Practices Georgia Department of Human Services

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE DEPARTMENT AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY This notice is effective April 14 2003 It is provided to you pursuant to provisions of the Health Insurance Portability and Accountability Act of 1996 and related federal regulations If you have questions about this Notice please contact the Legal Services Office at the address below

The Department of Human Services is an agency of the State of Georgia responsible for numerous programs which deal with medical and other confidential information Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information and the Department must comply with those laws For situations where more stringent disclosure requirements do not apply this Notice of Privacy Practices describes how the Department may use and disclose your protected health information for treatment payment health care operations and for certain other purposes This notice relates only to health information It describes your rights to access and control your protected health information and provides information about your right to make a complaint if you believe the Department has improperly used or disclosed your protected health information Protected health information is information that may personally identify you and relates to your past present or future physical or mental health or condition and related health care services The Department is required to abide by the terms of this Notice of Privacy Practices and may change the terms of this notice at any time A new notice will be effective for all protected health information that the Department maintains at the time of issuance Upon request the Department will provide you with a revised Notice of Privacy Practices by posting copies at its facilities publication on the Departments website in response to a telephone or facsimile request to the Privacy Coordinator or in person at any facility where you receive services from the Department 1 Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by the Department its administrative and clinical staff and others involved in your care and treatment for the purpose of providing health care services to you and to assist in obtaining payment of your health care bills Treatment Your protected health information may be used to provide coordinate or manage your health care and any related services including coordination of your health care with a third party that has your permission to have access to your protected health information such as for example a health care professional who may be treating you or to another health care provider such as a specialist or laboratory Payment Your protected health information may be used to obtain payment for your health care services For example this may include activities that a health insurance plan requires before it approves or pays for health care services such as making a determination of eligibility or coverage reviewing services provided to you for medical necessity and undertaking utilization review activities Health Care Operations The Department may use or disclose your protected health information to support the business activities of the Department including for example but not limited to quality assessment activities employee review activities training licensing and other business activities The Department may use a sign-in sheet at the registration desk at any facility where services are provided You may be asked to provide your name and other necessary information and you may be called by name in the waiting room when a staff member is ready to see you and your protected health information may be used to contact you about appointments or for other operational reasons Your protected health information may be shared with third party business associates who perform various activities that assist us in the provision of your services

Other uses and disclosures of your protected health information will be made only with your written authorization which you may revoke in writing at any time except as permitted or required by law as described below Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to Object The Department may use and disclose your protected health information in the following instances You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information Unless you object the Department may disclose protected health information for a facility directory or to a family member relative or any other person you identify information related to that persons involvement in your health care and may use or disclose protected health information to notify or assist in notifying a family member personal representative or other person responsible for your care of your location general condition or death The Department may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care Objections may be made orally or in writing Permitted or Required Uses and Disclosures without Your Authorization or Opportunity to Object The Department may use or disclose your protected health information without your authorization when required to do so by law for public health purposes to a person who may be at risk of contracting a communicable disease to a health oversight agency to an authority authorized to receive reports of abuse or neglect in certain legal proceedings and for certain law enforcement purposes Protected health information may also be disclosed without your authorization to a coroner medical examiner or funeral director for certain approved research purposes to prevent or lessen a threat to health or safety and to law enforcement authorities for identification or apprehension of an individual Required Uses and Disclosures Under the law the Department must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine the Departments compliance with the requirements of the Privacy Rule at 45 CFR Sections 164500 et seq

Georgia DBS Form 5460 Include Privacy Contact information for Division Office or Facility in Item 3 Rev 1109

2 Your Rights under the federal Privacy Rule The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights You have the right to inspect and copy your protected health information Upon written request you may inspect and obtain a copy of protected health information about you for as long as the Department maintains the protected health information This information includes medical and billing records and other records the Department uses for making medical and other decisions about you A reasonable cost-based fee for copying postage and labor expense may apply Under federal law you may not inspect or copy information compiled in anticipation of or for use in a civil criminal or administrative proceeding or protected health information that is subject to a federal or state law prohibiting access to such information You have the right to request restriction of your protected health information You may ask in writing that the Department not use or disclose any part of your protected health information for the purposes of treatment payment or healthcare operations and not to disclose protected health information to family members or friends who may be involved in your care Such a request must state the specific restriction requested and to whom you want the restriction to apply The Department is not required to agree to a restriction you request and if the Department believes it is in your best interest to permit use and disclosure of your protected health information your protected health information will not be restricted except as required by law If the Department does agree to the requested restriction the Department may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment You have the right to request to receive confidential communications from us by alternative means or at an alternative location Upon written request the Department will accommodate reasonable requests for alternative means for the communication of confidential information but may condition this accommodation upon your provision of an alternative address or other method of contact The Department will not request an explanation from you as to the basis for the request You may have the right to request amendment of your protected health information If the Department created your protected health information you may request in writing an amendment of that information for as long as it is maintained by the Department The Department may deny your request for an amendment and if it does so will provide information as to any further rights you may have with respect to such denial You have the right to receive an accounting of certain disclosures the Department has made of your protected health information This right applies only to disclosures for purposes other than treatment payment or healthcare operations excluding any disclosures the Department made to you to family members or friends involved in your care or for national security intelligence or notification purposes Upon written request you have the right to receive legally specified information regarding disclosures occurring after April 14 2003 subject to certain exceptions restrictions and limitations You have the right to obtain a paper copy of this notice from the Department upon request All written requests regarding your rights as set forth above should be sent to the Privacy Coordinator for the DHS Division Office or facility which maintains your PHI 3 Complaints related to use or disclosure of your protected health information You may complain to the Department and to the Secretary of Health and Human Services if you believe your health information privacy rights have been violated You may file a complaint in writing with the pH~ Division Office or Facility which maintains your PHI at telephone (229) 377 - 7449 facsimile (229) 377 - 3277 or by mail to RSM Project Office 800 North Broad Street Cairo Georgia 39828 Attn Jamie M Anderson

You must state the basis for your complaint The Department will not retaliate against you for filing a complaint Mail your complaint to DFCS HIPAA Privacy Coordinator 2 Peachtree Street NW Suite 19-244 Atlanta Georgia 30303-3142 Please do not send your application for services to this address

Please sign a copy of this Notice of Privacy Practices for the Departments records

I have received a copy of this Notice on the date indicated below

Signature Mailing Address

(Please print name) Date City State Zip

After you sign and date please mail or bring the original to

RSMKatie Beckett Unit County Office Case Manager Load

5815 Live Oak Pkwy Suite 2-D Norcross GA 30093 Mailing Address City State Zip


Type of Program D Nursing Facility OGAPP

PEDIATRIC OMA 6(A) DTEFRAKatie Beckett

PHYSICIANS RECOMMENDATION FOR PEDIATRIC CARE Section A - Identifying Information 1 Applicants Name Address

Name

Address

DFCS County

7 Does guardian think the applicant should be institutionalized DYes ONo

Name of Caregiver 1

2 Medicaid Number 3 Social Security Number

4Sex Age 4A Birthdate

5 Primary Care Physician

6 Applicants Telephone

8 Does child attend school 9 Date of Medicaid Application

DYes ONo __j

Name of Caregiver 2

I hereby authorize the physician facility or other health care provider named herein to disclose protected health information and release the medical records of the applicantbeneficiary to the Georgia Department ofCommunity Health and the Department of Human Services as may be requested by those agencies for the purpose of Medicaid eligibility determination This authorization expires twelve (12) months from the date signed or when revoked by me whichever comes first

10 Signature 11 Date ___J__ (Parent or other Legal Representative)

Section B - Physicians Report and Recommendation 12 History (attach additional sheet ifneeded)

13 Diagnosis 1 ICD 2 ICD 3 ICD

1) 2) (Add attachment for additional diagnoses)

3)

14 Medications

Name Dosage Route Frequency

15 Diagnostic and Treatment Procedures

Type Frequency

16 Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)

Previous Hospitalizations Rehabilitative Services Other Health Services

Hospital Diagnosis 1) 2) Secondary 3) Other

17 Anticipated Dates ofHospitalization I1s Level ofCare Recommended D Hospital D Nursing Facility DICMR Facility

19 Type ofRecommendation Dlnitial

0 Change Level of Care D Continued Placement

20 Patient Transferred from (check one) 21 Length ofTime Care Needed __ Months 22 Is patient free DHospital DAnotherNF 1) 0 Permanent of communicable D Private Pay D Lives at home 2) D Temporary estimated diseases

OYes ONo

23This patients condition O could D could not be managed by provision of D Community Care orO Home Health Services

24 Physicians Name (Print)

Physicians Address (Print)

25 Icertify that this patient requires the level of care provided by a nursing facility ICMR facility or hospital

Physicians Signature

26 Date signed by Physician ____

27 Physicians Licensure No

28 Physicians Telephone

of2

Section C- Evaluation of Nursing Care Needed (check appropriate box only) 29 Nutrition

DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds

34 Integument System

D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal

39 Other Therapy Visits

D Five days per week

30 Bowel

D Age Dependent

I nconti ne nee

D Incontinent-Agegt 3 years

DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent

0 Less than 5 days per week

31 Cardiopulmonary Status

D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx

D Vital signs gt 2days

DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning

D Chest - Physical Tx

DRoomAir

36 Surgery

D Level 1 (5 orgt surgeries)

D Level II(lt 5 surgeries)

D None

40 Remarks

32Mobility

0 Prosthesis

OSplints

0 Unable to ambulate gt

18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services

D High Tech - 4 or more

times per week

D Low Tech -3 or less

times per week or MD

visitsgt 4 per month

DNone

33 Behavioral Status

OAgitated

D Cooperative

DAlert

D Developmental Delay

DMental Retardation

D Behavioral Problems

(please describe if checked)

OSuicidal

OHostile

38 Neurological Status

ODeaf

DBlind

Dseizures

D Neurological Deficits

DParalysis

ONormal

41 Pre-Admission Certification Number 142Date Signed ______

43 Print Name of MD or RN

Signature of MD or RN

DO NOT WRITE BELOW THIS LINE

44 Continued Stay Review Date Admission Date Approved for Days or Months

45 Are nursing services rehabilitative services or other health related

services requested ordinarily provided in an institution

DYes ONo

47 Hospitalization Precertification DMet DNot Met

46A State Authority MH amp MR Screening

Level 111

Restricted Auth Code Date

46B This is not a re-admission for OBRA purposes


48 Level of Care Recommended by Contractor DHospital D Nursing Facility 0 ICMR Facility

49 Approval Period SO Signature (Contractor) 51 Date 52 Attachments (Contractor)

_____ DYes DNo

DMA-6A (112011) Page 2 of2

IPHYSICIANS RECOMMENDAIONFOR PEDIATIUC CARE I INSTRUCTIQNS FOR COMPLETING THE PEDIATRIC CARE FORM DMA-sect(Al

This section provides detailed instructions fqr completion of the Form DMA-6 (A) Before payinent can be made a Form DMA-6 (A) must be completed by the Primary Care Physician (PCP) mu1the parent or legal representative ~d signed by the PCP Ibe Form DMA-6 (A) is considered valid only ifIt is signed by the Primary Care Physician and-dated middot

Section A - Identifying Information

It is the responsibility of the responsible party to see that Section A ofthe form is completed with middot the applicants name and address

Item 1 Applicants Name and Address Enter the complete name and address ofthe applicant including the city and

zipcode middot

The KB Medicaid Specialist will coinplete the mailing address and county of the originating application middot middot middot

Item 2 Medicaid Number Enter the Medicaid number exactly as it appears on ~e Medicaid card or Form 962 A valid Medicaid number will be fonnatted ~ one of three ways

a Ifthe member or applicant is in the Medicaid System the ID number will be the 12-digit number eg 111222333444

b If the member or applicant was previousiy detennined eligible by the KB Team stafor inaking application for services the number will be the 9-digit SUCCESS number plus a P eg 123456789P or

c Ifthe individual is eligible for Medicaid due middot10 the receipt of Supplemental Security Income (SSI) the number will ~ the 9-digit Social Security n~plus an S eg 123456789S

The endre-number must be placed on the form middotcorrectly In exceptional instances~ it may be necessary to contact the KB Medicaid Specialist for the Medicaid number middot

Item 3 Social Security Number Enter the applicants nine-digit Social Security number

Item 4amp4A Sex Age and Date ofbirth Enter the applicants sex age and date ofbirth

Item S Primary Care Pbysidan middotEnter the entire name ofthe Primary Care Physician (PCP)

Item 6 middot Telephone Number Enter the telephone number including area code ofthe applicants parent or ~e legal representative

Item 7 Does th~ parent or legal rep~tative~ the applicant should be middot institnffnnalfRd middot middot Please check the appropriate box

Item 8 Does the child attend scllool Please check the appropriate box if the member attends school

Iieni 9 Date o(Medicaid Application Enter the date the family made application for Medicaid services

Fields below Item 9 Please enter the name ofthe primary ~aregiver for the appli_cant If a secondary caregiver is available to care for the applicant please indicate the name ofthe caremver

Read the statement below the name(s) ofthecaregiver(s) and then

Item 10 Signature The parent or legal representative for the applicant should sign the DMA-6(A)

Item 11 Date Please include the date th~ DMA-6 (A) was signed by the parent or the legal representative

Section B -Physicians Exami~ation Rgortand Recommendation

Item 12 History (attaclt additional sheet(s) ifneeded) middot middot Describe th~ applicants medical history (Hospital records may be attached)

Item 13 Diagnosis (Add attachment(s) for atlditional diagnoses) Describe the primary secondary and any third diagnoses relevant to the applicants condition on the appropriate lines Leave die bJoclcs labeled iCD blank The Contractors staffwill complete these boxes middot

Item 14 Medications (Add affaJment(s) for additional medication(s) fhe name of all medications the applicant is to receive should be listed Name ofdrugs with dosages routes and frequencies of administration are to be includedshy

Item 15 Diagnostic and Treacment Proced~ Any diagnostic or_treatment procedures and frequencies should be indicated

Item 16 Treatment Plan (Attach copy oforder sheet ff more oonveni~t or other pertinent documentation) middot List previous hospitalization dates as well as rebabilitativelhabilitation and other health care services the applicant has received or currently receiving The hospital admitting diagnoses (primary secondary and other diagnoses) and dates of admission and discharge must be recorded The treatment plan may also include other pertinent documents to assist with the evaluation of the applicant

Item 17 Anticipated Dates ~fHospitalization List any dates the applicant may be ~ospitalized in die nearQture for services

Item 18 Level of Care Recommended Recommendation regarding the level ofcare consid~ necessary Enter a check in the correct box for hospital nursing facility or an intetmediate care

facility for the mentally retarded

Item 19 middot Type ofRecommendation Indicate if this is an initial recommendation for services achange in the members level ofcare or a continued placement review for the member

Item 20 Patient Transferred from (Check one) Indi~ if the applicant was transferred from a hospital private pay another nursing facility or lives at home

Item 21 Length of Time Care Needed Enter the length middotof time the applicant will require care and services from the Medicaid program Ch~k the appropriate box on themiddotlength of time care is needed either pennanent or temporary ff temporary please provide an estima~ ofthe length of time care will be needed

Item 22 Is PatientmiddotF~ ofCommunicable Diseases Enter a check in the appropriate box

Item 23 middot Alternatives to Nursing Facility Phueinent The admitting or attending physician must indicate whether the appli~tmiddots condition could or could not be managed by provision ofthe Communitymiddot Care or Home Health Care Services Programs Enter a checkin the box corresponding to could aild eitherboth the box (es) corresponding to_ Community Care andor Home Health Services ifeitheror both is appropriate Enter a check in the box_ corresponding to could not if neither is appropriate

Item 24 Physicians Name and Address Print the admitting or attending physician_s name and address in the spaces provided

Item 25 Certification Statement of Che Physidan and Signature The admitting or attendbig physician must certify that the applicant requires the level ofcare provided by a nursing facility hospital or an intermediate care facility for the mentally retarded Signature stamps are not acceptable

Item 26 Date signed by Che physician Enter the date the physician signs the form

Item 27 Physicians Licensure Number Enter the Georgia license n~ber for the attending or admitting physician

Item 28 Physicians Telephone-Number Enter the attending or admitting physicians telephoIJemiddotnumbet including area code

Section C Evaluation of Nursing Care Needed (Cheek Appropriate box only)

Licensed personnel involved in the care of the applicant should complete Section C of this form middot

Item 29 Nutrition Check the appropriate box (es) regarding the nutritional needs of the applicant

middot Item 30 Bowel Check the appropriate box(es) to indicate the bowel and bladder habits of the applicant middot

Item 31 CardiopulmonaryStatus Check the appropriatebox (es) to indicate ~e-ciudiopulmonary status of the applicant middot middot

Item 32 middot Mobiljty Check the appropriate box (es) to indicate the mobility ofthe applicant

Item 33 Behavioral Staiis Check all appropriate boxes (es) to indicate the applicants mental and behavioral status

Item 34 Integument Systemmiddot Check the ~ropriate box (es) to indicate the integument system of the middot applicant

middot Item 35 Urogenital Check the app~priate box (es) for the urogenital functioning of the applicant

Item 36 Surgery middot Check the appropriate box regardmg the number ofsurgeries the applicant has had to your knowledge ot obtain this information from the parent or other legal middotrepresentative middot

Item 37 TherapyNisits Check the appropriate box to indicate the amount of thempy visits the applicant receives

Item 38 Nturologi~ Staeus middot Check the appropriate box(es) regarding tbemiddotneurological status of the applicant

Item 39 0th~ Therapy Visits H applicable indicate the number oftreatment or therapy sessions ~rweek the applicant receives or needs middot

Item 40 Remarks middot Indicate the patients vital signs height weight and other pertinent information not otherwise indicated on this fonn or any additional comments

Item 41 Pre-admission Certification Nuniber Indicate the pre-admission ceriification_number (ifapplicabl~)

Item 42 Date Signed Enter the datethis section of the fonn is completed

Item 43 Print Name ofMD or RN The individual completing Section C should piint their name and sign the DMA6(A)

Qo Not Write BdowThis Line Items 44 through 52 are completed by Contractor staffonly

------------- -------------

----- -----

TEFRAKatie Beckett Cost-Effectiveness Form

(Childs physician must complete Form)

The following information is requested for the purpose of determining your patients eligibility for Medicaid

Patients Name Medicaid

Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _

Please provide the estimated monthly costs ofMedicaid services your patient will need or is seeking for Medicaid to cover for in-home care

bull Physicians services $_ ______

bull Durable medical equipment bull Drugs bull Therapy(s) bull Skilled Nursing Services bull Other(s) _ ______

TOTAL $___ ____

Will home care be as good or better than institutional care

Yes No

COMMENTS

PHYSICIANS SIGNATURE ___ _____ ____________

DATE ________ ______________________

DMAForm 704 Rev 10-04

Instructions for Completing the Katie Beckett Cost-Effectiveness Form

middotThis fonn should be completed by the Katie Beckett childs primary care physician Instruct the physician to complete the form asmiddot follows

bull Patients Name- Enter the name ofthe Katie Beckett child bull The MES may provide the Medicaid number ifnot known bull The physician shoutd enter the diagnosis name not the ICD code and

the prognosis in the ~aces provided She may attach additional infonnation ifneeded

bull The physician should provide the estimat~ monthly cost ofany of the medical services which the Katie Beckett childmiddot regularly receives If the physician will not complete everything applicable it is permissible to have other medical service amounts middotentered by the providing agencypharmacytherapist Have_ that entity initial-next to the dollar amount At the very least the physician must complete the cost of hisher services middot

bull The middotphysician must indicate ifhome caremiddotwiJJ be as good as institutional care

bull It is not necessary to enter any coinments However it will be helpful to the MES ifyou will indicate for each medical service the percentage amount that is covered by any privategroup insurance plan middot

bull Th~ form must have an original signature ofthe primary care physician Stamped signatures are not acceptable The date should be the date ofthe signature

- ----------- --- - ----- --

--- ---------

TEFRAKatie Beckett Medical NecessityLevel of Care Statement

Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy

Recommended level of Care CJ Nursing facility level of care CJ Hospital level of care CJ Level of care required in an Intermediate Care Facility for MR (ICF-MR)

Medical History (May attach hospital discharge summary or provide narrative)

Current Needs

None Description of Skilled Nursing Needs Cardiovascular Neurological Respiratory Nutrition Integumentary Urogenital Bowel Endocrine Immune Skeletal Other

Therapy Speech sessionswk _ _ PT sessionswk OT sessionswk _ _ (attach current notes)

Hospitalizations within last 12 months (Attach most recent hospital discharge summary) Date ____ Reason_____ Duration ________ ____ Comments - ---shy ----shy - - - ----------- shy ---shy

Child in school __ Hrs per day __ Days per wk_ N I A __ IEPIFSP _ (attach ifin effect) Nurse in attendance during school day __ NI A __(attach last months nursing notes)

Skilled Nursing hours received Hrsday ___ NI A ____ I attest that the above information is accurate and this member meets Pediatric Level ofCare Criteria and requires the skilled care that is ordinarily provided in a nursing facility hospital or facililty whose primary purpose is to furnish health and rehabilitative services to persons with mental retardation or related conditions

Physician s Signature Date Primary Caregiver Signature Date

Foster Care Applicants must have the signature of the DFCS representative

DMA - 706 Rev 0811

TEFRAKATIE BECKETT MEDICAL NECCESSITYLEVEL OF CARE STATEMENT INSTRUCTIONS FOR COMPLETION

This document provides detailed instructions for completion of the TEFRAKatie Beckett Medical NecessityLevel of Care Statement

Member (Applicant) Information 1 Enter the Member s Name DOB and SS

Diagnosis 1 Enter the Members primary secondary and any third diagnoses relevant to the

members condition

Level of Care 1 Enter a check in the correct box for the recommended level of care

Medical History 1 Provide narrative of members medical history or attach documents ie hospital

discharge summary etc

Current Needs 1 Check members current needs and provide description of skilled nursing needs

Therapy 1 Include frequency per week oftherapies and attach current notes

Hospitalizations Attach most recent hospital discharge summary and document date reason and duration

School 1 Enter a check for member s appropriate school attendance and IFSP or IEP plan

Signature 1 The primary care physician or physician ofrecord must sign and date 2 The caregiver (parent or guardian) must sign and date Foster Care members must have

the signature of the DFCS representative

DMA-706 Rev 0811

GEORGIA DEPARTMENT OF COMMUNITY HEALTB-1HIRD PARTY LIABiLITY HEALTH IN~CE INFORMATION QUESTIONNAIRE

CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy

1YPE OF CASE CChcclc a11 that apply)

C INmAL APPLICATION a IIlPJgt REFERRAL

0 SPECIAL NEEDS TRlJST (SN1) aCHANGE 0 CANCELL41)0N EFFECTIVBDATEOFCHANGEORCANCELLATION _I I tif middot

vmiddot middot The information~on this form is collected by the Georgia Department ofCommlDlity Health Third Party LiabilitySection The collection ofthis~~ is authorired by law42 USC 1396(a) (25) 42 CFR 433135-139) lt will be used to detaminc the liability ofthird parties to pay for care and services and ceilleclion ofthat liability Medicaid ~fitsan not denied based on any applicant having health insuiancc or medicaJ coverage

Doyou have a private pgtUp orgovem1nent health insurance that pays any ofthe cost ofyour CYES CNO Is policyholderan Absent Pamrt medical care (Dq not include Medicare or Medicaid)

CYES ONODoes yom spouse parent orstepparent have anrprivate group or government health insunmce DYES ONO thirt~sany of1he ~ ofyour medical aR _

Names ofCovered Individuals in Household Relationship to Policy Holder Medicaid ID middot (checkone)SSN Date

Policy middot QlildSpouse Stejgtshy Other Of rr alti1l (First) (Mfl childHolder Birth

Are any ofthese persons pregnant CJ YES O NO Ifyes Name ______~----Date ofDelivery___

AITACIIA COPY OF INSURANCE Do any of1he persons listed above have a chronic medical condition DYES ONO If yesName middot Condition middot -CARDPOUCY ANigt ACOPY OF SNT

-=-----=c--------------------------___--------~(i___J)__~---shy~ceCompany N~) (Telephone Number)

(Admas) (Cify) (State) (Zip)

(PolicyholderName) (Policyholder SSN) (Policy NIJllber) (Policyholder DOB)

Types ofCovrage (cinle those which apply) (Policy Effective Date) middot (Policy Terminaticin Date)

(Fmploye( Name) (Telephone Number)

(Fmployer Address) (Cify) (State) (Zip)

01 -HOSPITALINPT lS-LTCNH 07- DRUGSTND 16-HMODRUG 08-MAJORMED 17-MFD SUPP A_ 09-DENTAL 18-MFJgt SUPP B IO-VISION 2i-HMOSTND OnmR____________

I authoriu the release ofinformation necessllI) to identify heaithliability insurance I hereby assign to the Department ofCommunify Health all rightsbenefits to the Department ofCommW1ity Health I also certify that the above middot to payments for benefits ofmedical services rmdered to myselfor

middot information is correct middot any ofmy dependents who receive Medicaid

Signed_________----Date____Signed~~-------------c-------Date------ shyMember or Authorized Person Insured or Authomed Person

EFFECTVIE DATE OF MEDICAID ELIGIBILIIY__________

Case WorkerName________________Phone No__________County_------- shy

DMA-285-REV (0106)

INSTRUCTIONS FOR COMPLETING GEORGIA DEPARTMENT OF MEDICAL ASSISTANCE

THIRD PARTY LIABILITY HEALffl INSURANCE INFORMATION QUESTIONNAIRE

FORM DMA-285

1 LEGIBLY PRINT information in every applicable field on the form 2 Hthe DMA-283 is for a iegal action Trust or QIT write Legal Action

TRUST or QIT in red ink at the top ofthe fo~ 3 Hthis fonn is completed to report a change persoJ)31 reimbmicrorsement death or

cancellation ofan insurance policy write ~ge~ Cancellapo1f Death1

Reimbursement etc in red ink atthe top ofthe form Yott maymiddotuse a copy of the original 285_sent to DMA ifit is legible middot middot bull Ifyou have a letter confirming cancellation ofthe policy attach the letter ~o

middotthe 285 bull Hthe AIR has never had the insurance or ifit was cancelled several years

ago attach to a 285 a copy ofthe MHN screel1 showingthe~and annotate that the AIR has never bad or has not had the insurance in years

bull ff you are reporting the death ofan AIR who has a QIT also write the date of death next to Death as MMDDYY middot middot

bull Ifthe AIR has personally been reimbursed for a service covered byMedicaid or bas received a settlement from a pending legal action mailfax a copy of the existing 285 and attach a copy ofthe Explanation ofBenefits (BOB) or letter outlining the settlement that accompanies the check Attach a copy of the check ifavailable

middot 4 Do not submit this form ifthC only health insurance the AIR(~) have is Medicare orMedicaid

middotS Complete the name and address etc ofthe head ofhousehold in the AU as entered in SUCCESS

6 Check whether the case is for an application or redetermination 7 Ifyou plan to send this form to DMA for an active policy trust etc check Yes

to having aprivate group or government health -insurance 8 Check yes or no as appropriate ifsomeone else has health insurance on the

AR(s) 9 Check the appropriate type ofpolicy that exists for the AR(s ) Attach a copy of

the front and back ofthe health insurance ~d ifpossi1gtle middot 10 Ifthe fonn is for a trust or QIT cross out Policy Holder and write in Trustee

Enter the name ofthe policy holder or trustee 11 Enter the address ofthe policy holder or trustee as appropriate 12 Enter the policy holders SSN 13 Enter the phone number ofthe policy holder or trustee 14 Enter the name address policy number and effective date in the appropriate fields

Ifinsurance is cancelled write Cancelled above Effective Date and the date cancelled in the space available middot

15 Ifthe insurance policy is through an employer enter the information pertaining to the employment in the spaces middotpr~vided

Rev 0107

16 List the names ofthe household members who are Medicaid ARs covered ~der the insurance policy Enter th~ relatioJ1$ip to the AIR given as the Case Name at the top ofthe fomi Ifitbulls the $Ulle write Selfbull Provide the date of birth Enter the SUCCESS ID Enter the SSN ofthe individual

17 Ifpossible have middotthe AIR or PR sign the document mthe two spaces provided 1s f4e worker should LEGIBLY PRINT hisher name DIRECT phone nwnber and

DFCS county 19 See Section 2230 for mailingfaxing instructions

NOTE PCG the entity charged with handling DMA-285 has middota 30 day standard of promptness If it is necessacy to have an immediate correction made concerning a TPR fax the informationto PCG rather than mailing At times MHNmay show insurance coverage that the MES is not aware of Always double check with the AIR ~fore assuming that the insurance shQWJi is not valid However a phannacy should never deny a member their prescriptions because ofTPR issues Theyhave override codes to enter to mak~ the prescription claim be accepted

Rev 0107

We will consider this application without regard to race FOR COUNTY USE ONLYMEDICAID APPLICATION color sex age disability religion national origin or Date Received in County Dept political belief D Pregnant Woman D Families wChildren - LIM

Check block(s) that D Child(ren) Only- RSM D Chafee Independence Program Medicaid

apply to you DKatie Beckett Were you in foster care on your 18th birthday D Yes D No In which state __

PLEASE NOTE A Face to Face interview is not required for Medicaid applications Please answer all questions as completely and accurately as possible Ifyou cannot understand or complete this application Please notitv lJtCS start and assistance will be provided free of charge

Your Name (Please Print) FIRST MI Last Maiden (if applicable) Todays Date

Mailing Address City State IZip Code

Residence Address (if different from Mailing Address) Phone Number(s) E-mail Address

Please list all persons living with vou for whom vou want Medicaid List vourself if vou want Medicaid for vourself

Is this Person a

US Does the Citizen Father of Does the (YIN)

this child Mother of(you may live in this child qualify for

Medicaid your live in your Suffix Sex Social Security even if you home home

First Name MI Last Name (Jr) Race MIF Date ofBirth Relationship to You Number answer No) (YIN) (YIN)

Please list all persons living with you for whom you DONT want Medicaid List yourself ifyou dont want Medicaid You do not have to provide a SSN or immigration status information for any person who is not asking for Medicaid If provided we will use the SSN for computer matches with other agencies and it may help us process your childs application We will NOT share your

--- --- middot-middot-------- -1 ---shy

Is anyone in the household pregnant D Yes D No Ifyes who is pregnant ___________ Due Date _____ _ Please attach verification of pregnancy if available Do you have any unpaid medical bills from the past three months D Yes O No Ifyes which months ___ _______ __________________

Does anyone in your household have Health Insurance D Yes D No If yes list Insurance Company and policy number

Have you or anyone in your household been diagnosed with Breast or Cervical Cancer D Yes D No Ifyes have you received Womens Health Medicaid previously D Yes O No

Form 94 (1110)


Income

WagesEarnings

Current Employer

WagesEarnings





~0middot1 r~



Resources

Cash

Checkine Account

Savings Account


Who Owns Resource






middot~bull r









orm 94 (1110)

- -- --













I _________________ (PRINT NAME)




(DATE)

(DATE)

Form 94 (1110)



















Name

Address

DFCS County


Name of Caregiver 1






DYes ONo __j

Name of Caregiver 2






3)

14 Medications



Type Frequency








OYes ONo









Page 1 of2


DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds


D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal



30 Bowel

D Age Dependent

I nconti ne nee


DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent



D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx


DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning


DRoomAir

36 Surgery



D None

40 Remarks

32Mobility

0 Prosthesis

OSplints


18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services


times per week




DNone


OAgitated

D Cooperative

DAlert


DMental Retardation



OSuicidal

OHostile


ODeaf

DBlind

Dseizures


DParalysis

ONormal








DYes ONo



Level 111






_____ DYes DNo

DMA-6A (112011) of2






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107


Income

WagesEarnings

Current Employer

WagesEarnings





~0middot1 r~



Resources

Cash

Checkine Account

Savings Account


Who Owns Resource






middot~bull r









orm 94 (1110)

- -- --













I _________________ (PRINT NAME)




(DATE)

(DATE)

Form 94 (1110)



















Name

Address

DFCS County


Name of Caregiver 1






DYes ONo __j

Name of Caregiver 2






3)

14 Medications



Type Frequency








OYes ONo









Page 1 of2


DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds


D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal



30 Bowel

D Age Dependent

I nconti ne nee


DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent



D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx


DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning


DRoomAir

36 Surgery



D None

40 Remarks

32Mobility

0 Prosthesis

OSplints


18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services


times per week




DNone


OAgitated

D Cooperative

DAlert


DMental Retardation



OSuicidal

OHostile


ODeaf

DBlind

Dseizures


DParalysis

ONormal








DYes ONo



Level 111






_____ DYes DNo

DMA-6A (112011) Page 2 of2






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107

- -- --













I _________________ (PRINT NAME)




(DATE)

(DATE)

Form 94 (1110)



















Name

Address

DFCS County


Name of Caregiver 1






DYes ONo __j

Name of Caregiver 2






3)

14 Medications



Type Frequency








OYes ONo









Page 1 of2


DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds


D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal



30 Bowel

D Age Dependent

I nconti ne nee


DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent



D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx


DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning


DRoomAir

36 Surgery



D None

40 Remarks

32Mobility

0 Prosthesis

OSplints


18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services


times per week




DNone


OAgitated

D Cooperative

DAlert


DMental Retardation



OSuicidal

OHostile


ODeaf

DBlind

Dseizures


DParalysis

ONormal








DYes ONo



Level 111






_____ DYes DNo

DMA-6A (112011) Page 2 of2






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107



















Name

Address

DFCS County


Name of Caregiver 1






DYes ONo __j

Name of Caregiver 2






3)

14 Medications



Type Frequency








OYes ONo









Page 1 of2


DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds


D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal



30 Bowel

D Age Dependent

I nconti ne nee


DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent



D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx


DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning


DRoomAir

36 Surgery



D None

40 Remarks

32Mobility

0 Prosthesis

OSplints


18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services


times per week




DNone


OAgitated

D Cooperative

DAlert


DMental Retardation



OSuicidal

OHostile


ODeaf

DBlind

Dseizures


DParalysis

ONormal








DYes ONo



Level 111






_____ DYes DNo

DMA-6A (112011) Page 2 of2






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107


DRegular

D Diabetic Shots

0 Formula-Special

0 Tube feeding

D NG-tubeG-tube

0 Slow Feeder

D FTT or Premature

DHyperal

DIV Use

D MedicationsGT

DMeds


D Burn Care

D Sterile Dressings

DDecubiti

DBedridden

D Eczema-severe

ONormal



30 Bowel

D Age Dependent

I nconti ne nee


DColostomy

OContinent

OOther

35 Urogenital

D Dialysis in home

Oostomy


D Catheterization

D Continent



D Monitoring

0 CPAPBi-PAP

DCP Monitor

DPulseOx


DTherapy

Doxygen

DHomeVent

DTrach

0 NebulizerTx

0 Suctioning


DRoomAir

36 Surgery



D None

40 Remarks

32Mobility

0 Prosthesis

OSplints


18 months old

0 Wheel chair

ONormal

37TherapyNisits

Day care Services


times per week




DNone


OAgitated

D Cooperative

DAlert


DMental Retardation



OSuicidal

OHostile


ODeaf

DBlind

Dseizures


DParalysis

ONormal








DYes ONo



Level 111






_____ DYes DNo

DMA-6A (112011) Page 2 of2






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107






zipcode middot























































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107















































------------- -------------

----- -----





Diagnosis__________ ________________ ___ _ _ _

Prognosis_________________ _____________ _ _




TOTAL $___ ____


Yes No

COMMENTS


DATE ________ ______________________










- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107









- ----------- --- - ----- --

--- ---------


Member Name DOB SS

Diagnosis - ----- ------- ----------- - - ---- ------ shy



Current Needs








DMA - 706 Rev 0811





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107





members condition










DMA-706 Rev 0811


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107


CASENAME_____________ CASE NO_____________

ADDRESS SSN

PHONE NO_ ___------------ shy























DMA-285-REV (0106)



FORM DMA-285


















Rev 0107





Rev 0107



FORM DMA-285


















Rev 0107





Rev 0107





Rev 0107

Katie Beckett Packet - Forsyth County Schools Beckett...DKatie Beckett . Were you in foster care on...

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Transcript of Katie Beckett Packet - Forsyth County Schools Beckett...DKatie Beckett . Were you in foster care on...