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Family and Children's Medicaid MA-3405 TWELVE MONTHS TRANSITIONAL MEDICAID

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VII. AUTOMATED TRANSITIONAL BENEFIT REPORTING

REVISED 11/01/11 - CHANGE NO. 15-11

(VII.A.)

REISSUED 11/01/11 - CHANGE NO. 15-11

(VII.B.2.)

REVISED 11/01/11 - CHANGE NO. 15-11

(VII.C.)

XXX *** WORK FIRST/TRANSITIONAL QUARTERLY REPORTING *** Report Month

Current Date

COUNTY: __ DISTRICT: ___ CASE ID: ________ LAST NAME: __________ TYPE: _

MR

STATUS RPT CASE ID DIST CO CASE LAST NAME FIRST NAME MI FSIS TYPE

X XXXXXXX XXX XXXXXX XXXXXXXXXXXXX XXXXXXXXXXXX X XXX X

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ENTER = UPDATE PF7/19 KEY = PAGE BACK PF8/20 KEY = PAGE FORWARD

SELECTION -- KEY

REISSUED 11/01/11 - CHANGE NO. 15-11

(VII.D.)

(VII.)

    EJAXXX XX EIS TRANSITIONAL BENEFITS REPORTS TRACKING

    CASE-ID XXXXXXX

    CO XX CO-CASE XXXXX DIST XXX WORKER XXX PAY TYPE X

    CASEHEAD/PAYEE XXXXXXX X XXXXXXXXXX XXX PHONE NUMBER XXXXXXX

    ADDRESS LINE 1 XXXXXXXXXX ADDRESS LINE 2 XXXXXXXXXX

    CITY XXXXXXXXXX STATE XX ZIP CODE XXXXXXXXXX

    TRANSITIONAL REPORT REPORT

    MONTH MONTH RESPONSE

    01 05/01 ___

    02 06/01 ___

    03 07/01 ___

    04 08/01 ___

    05 09/01 ___

    06 10/01 ___

    07 11/01 ___

    08 12/01 ___

    09 01/02 ___

    10 02/02 ___

11 03/02 ___

12 04/02 ___

    ENTER = UPDATE PF2/PF14 = INQUIRY MENU

    SELECTION -- KEY ----------

(VII.E.2)

(VII.G.)

(VII.G.)

REVISED 01/01/06 - CHANGE NO. 04-06

(VII.G.)

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