The Economic and Employment Services Manual       01-18 MISCELLANEOUS FORMS

Miscellaneous Forms are created by agencies/divisions outside of EES and are placed in the KEESM for the convenience of staff.

Administrative Hearings
Department of Administration
Disability Determination
Fraud
HealthWave
HIPAA
HIPPS
 Integrated Service Delivery
Miscellaneous
Refugee/Repatriation Program

ADMINISTRATIVE DISQUALIFICATION HEARINGS

Item Number

Revised
Date

PROGRAM SECTION

File
Format

11-03

Action Taken on Your Administrative Disqualification Hearing (Not Guilty)*

DOC

PDF

11-04

Action Taken on Administrative Disqualification Hearing (Guilty)*

DOC

PDF

11-04

Action Taken on Administrative Disqualification Hearing (Waiver)*

DOC

PDF

Advance Notice of Administrative Disqualification Hearing*

 

PDF

01-03

Waiver of Right to Administrative Disqualification Hearing

 

PDF

ADMINISTRATIVE HEARINGS

Item Number

Revised
Date

PROGRAM SECTION

File
Format

   

Administrative Hearing Brochure

DOC

PDF

 

01-03

Notice of Withdrawal of Appeal

 

PDF

   

Decision Compliance Report*
(Staff will get this form if the fair hearing is reversed and staff have to take action to correct the case.)

DOC

PDF

         

FRAUD

Item Number

Revised
Date

PROGRAM SECTION

File
Format

FRS-1
01-09
Referal for Alleged Client Fraud XLS
       

HIPAA

Item Number

Revised
Date

PROGRAM SECTION

File
Format

ADM-2000

04-03

Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice)

 

PDF

ADM-2000S

02-05

Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice) (Spanish)

 

PDF

INTERNAL REVENUE SERVICE

W-9 10-07 Request for Taxpayer Identification Number and Certification   PDF
         

REPATRIATION PROGRAM

Item Number

Revised
Date

PROGRAM SECTION

File
Format

 

Emergency and Group Processing Form

 

PDF

 

Emergency and Group Repatriation Financial Form 

 

PDF

Federal Interagency Emergency Repatriation Workgroup (FIER) Contact Form

 

PDF

 

 

Loan Waiver Request Form

 

PDF

 

 

Non-Emergency Monthly Financial Statement Form

 

PDF

 

 

Privacy and Repayment Agreement Form

 

PDF

 

 

Refusal of Temporary Assistance Form

 

PDF

 

 

State Request for Federal Support Form

 

PDF

 

 

Temporary Assistance Extension Request Form

 

PDF

*EES staff information only.