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Appendix C Forms and Notices

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NORTH CAROLINA DIVISION OF SERVICES FOR THE BLIND
PROGRAMS AND FACILITIES SECTION
SPECIAL ASSISTANCE FOR THE BLIND PROGRAM


Section:

Appendix C

Title:

Forms and Notices

Revision History:

Revised 08/02


INSTRUCTIONS FOR COMPLETION OF DSB-7204

Check the appropriate box to indicate if the DSB-7204 is being completed for an application, re-application, or review.

Check the appropriate box to indicate if the a/r is in or entering a domiciliary care facility or living in his/her own home (individual). Domiciliary care includes both adult care homes and specialized residential community centers for children.

Enter the name of the a/r, the county of legal residence based on requirements in the section on Residency in Chapter 4, and the name of the Social Worker for the Blind for the Worker’s Name.

1. and 2. Enter all current identifying information about the a/r requested in these items.

3. and 4. Enter specific information requested about current residency status. This is necessary to determine eligibility for SAB based on U.S. and N.C. residency requirements. Also provide legal birth date based on SSA data, birth certificate, etc. (see section on Age in Chapter 4), race, sex, and marital status.

5. Enter the requested information about the ACH or specialized community residential center. It is necessary to attach a current FL-2 or MR-2 form for an application or a review.

6.-10. Enter all requested numbers for a/r and spouse as all sources of possible income must be explored and verified. Medicaid status and veteran status must also be documented. Enter previous status regarding receipt of SAB.

11. If a/r is applying for SAB in his/her own home, then complete information requested in this items. Omit this item if a/r is residing in an ACH or specialized residential community center.

Income and Resources:

1.-10. Enter specific information and attach documents necessary to verify information as requested.

Expenses:

Complete this section only if a/r is applying for SAB payment while residing in his/her own home.

Additional Information:

Both statements should be read carefully by or to the a/r and he/she must indicate if he/she is willing to respond in the affirmative. If not, the application will be denied.

The a/r should also read or have read to him/her the “Your Rights to Appeal” section.

The additional statements must be read by or to the a/r and he/she must sign and date the statements with appropriate witnesses where requested.

It is also necessary for the person who assisted in the completion of the form to sign, date, and provide his/her address in case the SAB Eligibility Specialist should need to make contact to clarify something on the form.

The information about G.S. 111-28 and G.S. 111-23 must be read by or to the a/r.

Page 9 serves as a release of information form for various public and private organizations and must be signed and witnessed before the application or review can be processed.

MEDICAL EXPENSE FORM—INSTRUCTIONS

Enter the information about medication not covered by Medicaid and then have the list verified by the pharmacist. As indicated, the cost of co-payments is not to be included on this form. The pharmacist must sign and write in the name of the pharmacy at the bottom of the form.

If the a/r has a change in this information after the application or review is approved, another Medical Expense Form can be completed at any time and forwarded to the SAB Eligibility Specialist. Any necessary adjustments will be made in the SAB budget.

INSTRUCTIONS FOR COMPLETION OF DSB-7207

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Check the appropriate box to indicate if the application is new or a reinstatement.

Check the appropriate box to indicate if the revision in payment is the result of a redetermination of eligibility or a desk revision.

County: Enter county of legal residence.

Date: Enter date the form is completed.

Consumer’s Name: Enter the complete name.

Number in Budget: This number will always be one (1) if the a/r is residing in an ACH or a specialized residential community center. However, if the a/r is residing in his/her own home and is requesting benefits in that living arrangement, enter the number of persons who are legally in the family unit.

Address: Enter the current mailing address of the a/r.

Monthly Requirements

I. Personal Allowance: Enter $46 which is the current amount of the allowance but is subject to change by legislative action.

1.-4.: These items apply to an a/r who is requesting assistance in his/her own home. Select the item which describes the a/r’s situation and enter the allowance for that living arrangement from page 165.

5.: If the a/r is residing in an ACH or a specialized residential community center, enter the current adult care home rate which is established by the General Assembly. As of 10/1/07, the rate is $1,173 per month.

II. Medical Care Special:

Total Monthly Requirements:

Total Monthly Resources:

Monthly Resources

1. (A) Wages of Consumer:

2. Cash Contributions regularly available:

3. Net rentals from real estate:

4. Pensions:

5. Income from savings, insurance, Social Security, SSI, trust funds, V.A., etc.:

6. Other:

Unearned Income Disregard:

Total Monthly Resources:

Deficit:

Recommended Payment:

Additional Explanation:

INSTRUCTIONS FOR DSB-7209 SAB AUTHORIZATION

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

I. Name of A/R: Enter the identifying information as requested on the form. The mailing address should be entered rather than the residence address.

II. Accounting Classifications:

III. Authorization for: Check the appropriate block to indicate why the SAB Authorization is being completed.

IV. Check the appropriate block and enter the previous information at “From” and the new information at “To” for Change of Address and/or Change of Name or Payee.

V. Obtain the signatures of the persons identified in the positions and the date the person signed the form.

INSTRUCTIONS FOR DSB-7219 APPLICATION FOR CONFERENCE

The purpose of this form is to notify the Chief, Independent Living Services, Field Services Manager and County DSS of an a/r’s dissatisfaction with the service program and to request a conference concerning his/her dissatisfaction.

The Social Worker for the Blind will assist in the preparation of the DSB-7219 if requested.

DISTRIBUTION:

White - Chief, Independent Living Services Program in DSB State Office
Blue - DSB Field Services Manager
Yellow - County Department of Social Services
Pink - Appellant

INSTRUCTIONS FOR DSB-7206

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the form is prepared and mailed under the letterhead.

Enter the a/r’s name or the name of his/her payee and the mailing address where the asterisks appear on the form.

Enter the a/r’s name or the name of his/her payee in the salutation.

Enter the effective date of the SAB payment where the first asterisk is located on the second line of the first paragraph.

Enter the months for which an SAB payment will be received where the second asterisk is located on the second line of the first paragraph.

Enter the date when the a/r can expect to receive the first SAB check where the third asterisk is located on the second line of the first paragraph.

Enter the amount of the regular monthly SAB check where the asterisk is located on the third line of the first paragraph.

Enter the name of the county of legal residence of the a/r where the asterisk is located on the third line of the second paragraph.

Enter the date which is the fifteenth calendar day from the date the DSB-7206 is prepared where the asterisk is located on the fourth line of the second paragraph.

The signature of the SAB Eligibility Specialist should be affixed in the closing.

Enter the name of the Social Worker for the Blind in the county of legal residence of the a/r where the first asterisk is located beside the “cc:”.

Enter the county of legal residence of the a/r where the second asterisk is located beside the “cc:”.

The original of the letter is mailed to the a/r or his/her representative, a copy is mailed to the Social Worker for the Blind in the county of legal residence, and a copy is kept by the SAB Eligibility Specialist.

INSTRUCTIONS FOR DSB-7249 LETTER OF NOTIFICATION TO OPERATOR

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the form is being mailed to the ACH or specialized residential community center operator where the asterisk is located under the letterhead.

Enter the name of the recipient of SAB on the line provided after “Re:”.

The signature of the Director of the Division of Services for the Blind should be affixed in the closing.

The original of the DSB-7249 is mailed to the ACH or specialized residential community center where the SAB recipient resides and a copy is kept by the SAB Eligibility Specialist.

INSTRUCTIONS FOR APPROVAL FOR MEDICAL CARE SPECIAL ONE-TIME NOTICE

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the notice is prepared and mailed under the letterhead.

Enter the name and mailing address or the a/r or his/her payee where the asterisk is located above the salutation.

Enter the name of the a/r or his/her payee in the salutation.

Enter the name of the device for which the a/r requested financial assistance where the asterisk is located on one line, paragraph one.

Enter the county of legal residence of the a/r on line three, paragraph one.

The signature of the Director of the Division of Services for the Blind should be affixed in the closing.

Enter the county of legal residence of the a/r where the asterisk is located beside the “cc:”.

The original is mailed to the a/r, a copy mailed to the county of legal residence and a copy is kept by the SAB Eligibility Specialist.

INSTRUCTIONS FOR VERIFICATION OF RECEIPT OF MEDICAL CARE SPECIAL ONE-TIME NOTICE

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the form is completed and mailed under the letterhead.

Enter the name and mailing address of the a/r or his/her payee where the asterisk is located above the salutation.

Enter the name of the recipient of the medical care special one-time payment after “Re:” on the line provided.

Enter the name of the Social Worker for the Blind in the county of legal residence of the a/r.

Enter the date the SAB application was received by the SAB Eligibility Specialist in the area where the first asterisk is located on line one of paragraph one.

Enter the name of the device for the purchase of which the a/r received financial assistance where the first asterisk is located on the second line of paragraph one.

Enter the a/r’s name where the second asterisk is located on the second line of paragraph one.

Enter the effective date of the approval of the SAB application at the location of the asterisk on line three of paragraph one.

Enter the name of the recipient of the SAB medical care special one-time payment on line five of paragraph one where the first asterisk is located.

Enter the name of the device that was purchased at the location of the second asterisk on line five, paragraph one.

The signature of the SAB Eligibility Specialist should be affixed in the closing.

The original is mailed to the Social Worker for the Blind with copies going to the Chief of Independent Living and Medical Services, the Deputy Director of DSB, the Controller’s Office and one is kept by the SAB Eligibility Specialist.

INSTRUCTIONS FOR CHANGE AND ACTION NOTICE

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the notice is prepared and mailed under the letterhead.

Enter the name and mailing address of the a/r or his/her payee at the location of the asterisk above the salutation.

Enter the name of the a/r or his/her payee in the salutation.

Check the block which describes the action being taken in the SAB payment.

If the payment is being terminated, enter the month and year that represents the last payment for the a/r.

Explain the reason, giving Manual Chapter if a reduction or termination, that details why the action is being taken in the SAB payment.

Enter the name of the legal county of residence of the a/r where the asterisk is located on line three of paragraph three.

Enter the date which is fifteen calendar days after the date of the notice on line four, paragraph three.

The signature of the SAB Eligibility Specialist should be affixed in the closing.

Enter the name of the Social Worker for the Blind in the a/r’s county of legal residence in the area where the first asterisk is located after “cc:”.

Enter the county of legal residence where the second asterisk is located after the “cc:”.

The original notice is mailed to the SAB recipient, the Social Worker for the Blind receives a copy and the SAB Eligibility Specialist keeps a copy.

INSTRUCTIONS FOR THE NO CHANGE AFTER REVIEW NOTICE

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the notice is prepared and mailed at the asterisk under the letterhead.

Enter the name and mailing address of the a/r or his/her payee at the location of the asterisk above the salutation.

Enter the month and year the review of SAB eligibility was due where the asterisk is located in line one of paragraph one.

Enter the amount of the SAB payment on line two of paragraph two after the “$”.

Enter the date which is fifteen calendar days after the date of the notice at the asterisk on line two of paragraph three.

The signature of the SAB Eligibility Specialist should be affixed in the closing.

Enter the name of the Social Worker for the Blind in the a/r’s county of legal residence after the “cc:”.

The original notice is mailed to the a/r, a copy is sent to the Social Worker for the Blind, and a copy of the notice is kept by the SAB Eligibility Specialist.

INSTRUCTIONS FOR CHANGE OF ADDRESS NOTICE

THIS FORM IS COMPLETED BY THE SAB ELIGIBILITY SPECIALIST.

Enter the date the notice is prepared and mailed at the asterisk below the letterhead.

Enter the name and mailing address of the a/r or his/her payee at the asterisk above the salutation.

Enter the name of the a/r or his/her payee at the asterisk in the salutation.

Enter the new address of the a/r or his/her payee at the asterisk in the paragraph one.

Enter the month at the asterisk in paragraph two to indicate when the change of address will be effective on the SAB check.

Enter the date which is fifteen calendar days following the date of the notice at the location of the asterisk on line two of paragraph three.

The signature of the SAB Eligibility Specialist should be affixed in the closing.

The county of legal residence should be entered after the “cc:”.

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