This form replaces the following forms:
Policy governing the requirements for the use of the DSS-5027 can be found in the Requirements for the Provision of Services by County Departments of Social Services at:
or in PDF format at:
The form is to be completed or updated each time a service is requested or terminated, when income eligibility is determined or redetermined, and where service policy requires notification to the client when a service is reduced.
Barring the exceptions listed below, a client record (DSS-5027) must be established for any person for whom the services listed in this manual will be provided. Certain individuals, due to either the specific services they are receiving or the conditions under which they are eligible, must also have a client record in SIS. These include:
§ individuals who have been determined eligible for Adoption Assistance Benefits
§ individuals who participate in the Food Stamp Workfare Program
§ individuals receiving Work First services whose income is at or below 200% of the Federal Poverty Level
§ individuals who are Non-Custodial Parents receiving Work First services
§ individuals receiving Work First ARRA Subsidized Employment Services
It is not necessary to open a client record for the following individuals:
§ an individual who is receiving only Day Care Services for Children
§ an individual receiving only Transportation Services under Title XIX
§ a Work First Cash Assistance recipient receiving only Work First Services
§ those individuals for whom only application for Medicaid is being facilitated (Service Code 341 - Facilitating an Application for the Medicaid Program) and/or to whom Medicaid outreach activities (Service Code 342 - Outreach for Medicaid Services) are being provided.
A client record will be opened when a DSS-5027 is keyed and will be automatically closed when all the services have been terminated. When necessary, update a current DSS-5027 with new information and submit for keying. A “turnaround form” will be generated with the new information. Note: When a client applies for a service which will not be provided, enter the same date in the Date Requested and the Date Terminated Field. This will automatically open and close the record if there are no other open services in the service plan.
1. All Service Clients: Sections A, B, H
These Sections must be completed or updated each time a service is added or terminated.
2. Clients Who Must Make Application for Services: Sections A, B, C, G, H
A client’s signature must be obtained to document the request/application for the services listed in Section B. Where service policy allows other Forms to be used
in lieu of an application, Sections C and G do not have to be completed. However, the services planned must be entered in Section B.
A client signature is not required on the DSS-5027 when only referral, coordination and monitoring of medical services (Service Code 340 - Referral, Coordination and Monitoring of Medical Services) and/or arranging for transportation for a client to access Medicaid services (Service Code 343 - Arranging Transportation Services for Client to Access Medicaid Services) are being provided.
3. Clients for Whom Income is a Condition of Eligibility: Sections A, B, C, E, F, G, H
Section E documents the information necessary for a determination of eligibility on the basis of income. The other sections indicated must also be completed to support the application.
4. Clients Who Must Pay a Fee for, or have agreed to Voluntarily Contribute to the Cost of a Service: Sections A, B, C, E, F, G, and H
Complete Section E in addition to the appropriate Sections as instructed above when a fee for service is required from the client.
5. Clients For Whom A Service is Being Purchased: Sections A, B, C, D, F, G
Complete Section E in addition to the appropriate Sections as instructed above.
The form has four pages. The identification of the destination of each page is printed at the bottom right of each page. It is very important that each copy gets to the right destination because there is certain information, which is blanked out on two of the copies for purposes of compliance with policy governing confidentiality of client records.
Page 1 This copy is to be sent to the data entry unit for keying into the system.
Page 2 The second page is to be given to the client. This copy is the only copy, which has the client’s rights, and responsibilities spelled out on the back of the page. It is a legal requirement to provide this to an applicant.
Page 3 This page is for the purchase of service provider. This copy has certain confidential information blanked out.
Page 4 This last page is to be retained in the client record. If a client's signature is not a requirement, this copy may be destroyed as soon as a turnaround form has been received and filed in the case record. If a client's signature is a requirement, the form with the signature must be retained for three years.
An entry is required in all fields in Section A except those, which are specifically identified as optional or reserved.
Field 1. Client ID -- Record the eleven-digit identification number assigned to this client. This number is used as a common identifier for other services systems so it is important that only one ID# be assigned within the county for each individual service client. This number will remain unique to the county, i.e. it will not be transferred if the client becomes a service recipient in another county. If the client applies for services in another county, the second county will assign its own unique number.
Field 2. Client Name -- Record the client's last name, first name and middle initial in the appropriate spaces. Truncate any name that is too long for the allotted space.
Field 3. Client Social Security Number -- Record the client's Social Security number. If the Social Security number is unknown, enter all zeroes in the space available. Enter the valid Social Security number once received.
If all nines (9’s) are entered, the system displays an online error message.
Field 4. Date of Birth - Record the month, day, century and year of birth for the client. Use a leading zero for a month or day less than 10. Estimate if the exact date is unknown and update the record when this information becomes available.
Field 5. County -- Enter the standard two digit county code to identify the county which is originating the form.
Field 6. County Case (Optional Entry) -- Record any data used by the county to identify this client record. This entry may be a combination of numbers and letters.
Field 6A. Federally Recognized Tribe -- Record whether a youth is enrolled in or eligible for membership in a federally recognized tribe. "Federally recognized tribe" means any Indian tribe, band, nation, or other organized group or community of Indians, including Alaska Native village, or regional or village corporation, as defined in or established pursuant to the Alaska Native Claims Settlement Act.
Field 7. Other (Entry Allowed Only Under Special Instructions) -- This field is reserved. Refer to Section II of Appendix A for instructions and applicable tables (HCCBG clients).
An entry is required in all fields in Section B except those, which are specifically identified as optional or reserved.
Column 8. Decision -- See instructions for Section C below. This column is only required when circumstances require notification to the client. There is no need to make an entry in this Column when notification is not required.
Column 9. Services Requested -- Write in each service which was requested by the client or which is being planned by the agency in those circumstances where the agency has this responsibility by virtue of program policy.
Column 10. Service Code -- Enter the three-digit code which identifies the service entered in the Services Requested column.
Column 11. Date Requested -- Enter the date (Month, Day, Year) that the service is added to the service plan.
Column 12 Date Terminated -- Enter the date (Month, Day, and Year) after which the service will no longer be provided. This may be entered at the time the service is requested if it is known. If the service cannot be provided at all, this date will be the same as the date in Column 11 (Date Requested).
Column 13 Reason -- Enter the appropriate termination reason from the table in Appendix A.
Column 14 Special Use -- This field is reserved for the collection of service related information to meet a specific need. Refer to Section II of Appendix A for instructions and applicable tables.
This Section of the form, along with the information in Column 8 in Section B above, the worker's signature, the statement above the client's signature, and the information printed on the back of the client's copy of the form satisfy the legal mandate to notify clients about the action taken regarding their request for services and to inform them of their rights and responsibilities regarding the receipt of services.
Column 8 In Section B Above -- This field is to be used to document the decision regarding a request for service. An entry is required only in conjunction with the Notice of Action Taken (Section C.) This is because this field is used to inform the client. Enter:
"Yes" if the service can be provided as requested, or if the client must wait for a period of time before the service can be provided, and complete Line 1 in Section C.
"No" if the service cannot be provided and complete Line 2 in Section C.
"Change" if the service that a client has been receiving will be reduced or increased, and complete Line 3 in Section C.
Line 1. When the client will begin receiving the requested service at the time requested, or at a later date, and "Yes" was entered beside the requested service in Column 8, check the box and enter the first date on which the service will be provided and, if known, the last date. If this is unknown, line out "through ___________" at the end of this line.
Line 2. This line will be used for denying services at the time of application and for terminating services after a period of receiving services.
a) To deny services at the time of application when the client will not be receiving the requested service, enter "No" in Column 8 beside the service and line out “After _____________” in line 2. Use the remaining spaces to document the reason for the decision.
b) When the service has been provided but is to be terminated, enter "No" beside the service in Column 8, and on line 2 enter the last date on which the service will be provided in the space following the word “After”. Write in the reason the service will no longer be provided and cite the policy governing the termination of the service. Usually this will be the name and chapter number of the appropriate policy manual.
Line 3. When a client has been receiving a service which must be reduced, write "Change" in Column 8 beside the affected service and describe the modifications on the line provided.
The worker must enter the date that the decision was made regarding the receipt of service and sign the form. It can then be mailed or given to the client as appropriate.
Line 4. Check the appropriate box to indicate if there is a fee for the service or if the client has voluntarily agreed to contribute to the cost of the service. Indicate the amount, frequency and starting date of the fee or contribution in the spaces provided.
This section of the form is to be used for transmitting information to a purchase of service provider. To initiate service provision, line out the "/ no longer authorized" option, enter the name of the service, the effective date, the name of the provider and the Provider ID. To terminate the authorization, line through the "authorized /" option. If the service provider is to be responsible for collecting a consumer contribution, check the box to indicate this and fill in the amount, frequency and starting date for the contribution to be collected. The worker will sign and date the authorization in the space provided in Section E. If more than one service is being provided, photocopy page three of the DSS-5027 prior to entering information in this Section but after all other required information on the rest of the form has been entered. Make a copy for each additional provider and complete this Section on each of the copies as appropriate.
This Section is to be completed when income is a condition of eligibility for one or more of the requested services. This Section is blocked out on the provider copy.
The signature of the Social Worker is required in this Section when either Section C or D is completed.
The comment block next to Section G can be used to identify where to find documentation of continued need for the service, or to provide additional information to the client, etc. The space is blocked out on the Provider copy.
When program policy requires an application for services the client, or someone applying in behalf of the client, must sign and date the form. If the client signs with a mark, a signature of a witness is needed. Enter the date that the client signed the form.
This Section must be completed for all records. All fields require entries except those that are defined as optional or reserved.
Field 15. Case Manager Name – (See Field 16, Case Manager Number.) This field will automatically display the Case Manager Name associated with the valid Worker ID keyed in Field 16. Worker IDs and Worker Names are stored within the Services Information System and may be maintained using the Worker Identification System submenu. It is important to keep Field 16 (and thus, Field 15) current because the case management reports from this system, the Child Placement and Payment System (DSS-5094), the Central Registry for Abuse and Neglect Reports (DSS-5104), the MRS Database and the Adult Protective Services Register (DSS-5026) will be assigned from this field in this system.
Field 16. Case Manager Number -- Enter the Case Manager's unique 9-digit Worker ID assigned by the Services Information System (see below). Update this field when the Case Manager for an individual changes.
§ NOTE: Prior to June 1, 2007, the Case Manager Number was either the workers Social Security Number or a county-assigned alternative unique 9-digit identifier. On the night of May 31, 2007, Case Manager Numbers on active cases and those with Close Dates on or after 10/01/2006 will be converted to unique Worker IDs. Case Manager Numbers on DSS-5027s closed prior to 10/01/2006 will be redacted. Effective June 1, 2007, unique Worker IDs for new workers are assigned within the Services Information System using the Worker Identification System Main Menu. (Refer to Administrative Letter PM-REM-AL-0407 for details.)
§ When opening a new DSS-5027, re-opening a closed record, or updating a DSS-5027 that currently displays an INVALID Worker ID, key the current Case Manager Number (valid Worker ID) in Field 16. If a valid number is keyed, the Case Manager’s Name will be populated in Field 15.
Field 17. Local Use (Entry Optional) -- The county may use any or this entire field for its own purposes. Either letters or numbers or both may be used. Note: If special reports are needed by the county relating to its own use of this field, please get in touch with the Services Automation Branch (919) 733-7675 to discuss the feasibility of such reports.
Field 18. State Use (Entry Allowed Only Under Special Instructions) -- This field is reserved for collecting additional ad hoc information when needed. Refer to Appendix A for additional information regarding this field.
Field 19. Special Areas -- Enter the code(s) that reflects special characteristics of the client based on worker judgment, not necessarily legally or medically established definitions. Up to six characteristics or circumstances may be entered for each individual. It is important to enter as many as appropriate because this information is useful for justifying funding needs to meet specific problems.
Field 20. Reason -- Enter the reason that best describes why the individual entered the service system. Do not update this field unless the record has previously been closed and is being reopened. It is not meant to track client goals as they evolve through assessment and service provision. Rather, it is to identify what brought the client to the agency for services for each period of service receipt.
Field 21. Legal Status -- Enter the code which describes the current legal status of the individual. If none are appropriate, enter the code for Other or Unknown.
Field 22. Living Arrangement -- Enter the code which best describes the client's current living arrangement.
Field 23. Sex -- Enter the code, which identifies the sex of the client.
Field 24. Race -- Enter the code, which identifies the race of the client.
Field 25. In School -- Enter the code that best describes the type of school the individual is currently attending on a scheduled basis. (Refer to Appendix A.) Enter code “N” if the individual is not currently enrolled in school. Do not take holidays, breaks or summer vacation into consideration.
Field 26. Highest Grade -- For both individuals who are still in school and those who are no longer attending school, enter the highest grade achieved (successfully completed).
Field 27. Language Preference – Enter the two-character code to indicate the individual’s preferred language.
Field 28. Special Education Status –Record whether the youth is receiving special education at no cost to the parents, to meet the unique needs of a child with a disability.
Field 29. Race Declined –Record whether the youth or parent has declined to identify a race.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.