The Economic and Employment Services Manual       10-16 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

         

DISABILITY DETERMINATION

Item Number

Revised
Date

PROGRAM SECTION

File
Format

DD-1103

04-05

Authorization to Release Medical Information

DOC

PDF

DD-1104

07-02

Disability Determination Request - Medical Assistance Case

DOC

PDF

DD-1105

07-02

Disability Determination Data/Report

DOC

PDF

DD-1106

03-13

Medical Onset Data Verification

DOC

PDF

       

 

         

FRAUD

Item Number

Revised
Date

PROGRAM SECTION

File
Format

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

HEALTHWAVE

Item Number

Revised
Date

PROGRAM SECTION

File
Format

10-03

HealthWave 21 - Pregnancy Report Form

DOC

 

       

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

04-03

Authorization for Release of Protected Health Information

 

PDF

 

04-03

Authorization for Release of Protected Health Information (Spanish)

 

PDF

04-03

Protected Health Information Disclosure Tracking Log

 

 

PDF

HIPPS

Item Number

Revised
Date

PROGRAM SECTION

File
Format

MS-2504

01-05

Health Insurance Premium Payment Information Form

DOC

PDF

MS-2504.1

01-05

HIPPS Change Report Form

DOC

PDF

     

 

 

INTERNAL REVENUE SERVICE

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

MISCELLANEOUS

Item Number

Revised
Date

PROGRAM SECTION

File
Format

 

Definitive Medical Report

 

PDF

MS-2126

07-07

Notification of Nursing Facility Admission/Discharge

DOC

PDF

MS-2156

10-01

Medical Review of Emergency Services for Establishing SOBRA Eligibility

DOC

PDF

REFUGEE/REPATRIATION PROGRAM

Item Number

Revised
Date

PROGRAM SECTION

File
Format

 

Monthly Summary of Expenditures For Repatriation Cases

 

PDF

 

Monthly Case Summary Report (For Repatriation Cases)

 

PDF

ACF-120

12-95

U.S. Repatriate Program - Privacy Act Statement and Repayment Agreement

 

PDF

*EES Staff Information only.