The Economic and Employment Support Manual 10-08 MISCELLANEOUS FORMS

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

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

ADMINISTRATIVE 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	DOC	PDF
		Administrative Disqualification Hearing Brochure	DOC	PDF
		Advance Notice of Administrative Disqualification Hearing		PDF
		Decision Compliance Report	DOC	PDF
	01-03	Notice of Withdrawal of Appeal		PDF
	01-03	Request for Administrative Hearing		PDF
	01-03	Waiver of Right to Administrative Disqualification Hearing		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	02-84	Medical Onset Data Verification		PDF

FRAUD
Item Number	Revised Date	PROGRAM SECTION	File Format
FRS-1*	12-93	Referral of Alleged Client Fraud		PDF

HEALTHWAVE
Item Number	Revised Date	PROGRAM SECTION	File Format
	10-03	HealthWave 21 - Pregnancy Report Form	DOT
	04-99	HealthWave Change Request		PDF

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	Protected Health Information Disclosure Tracking Log		PDF
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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

Integrated Service Delivery
Item Number	Revised Date	PROGRAM SECTION	File Format
IS-7000	04-05	HOW CAN WE HELP?	DOC	PDF
IS-7000S	04-05	HOW CAN WE HELP? Español	DOC	PDF
IS-7001	04-05	CUSTOMER/FAMILY NEEDS IDENTIFICATION	DOC	PDF

MISCELLANEOUS
Item Number	Revised Date	PROGRAM SECTION	File Format
ALDS-1	01-01	Adult Learning Disability Screening (no copy or link)
		Child Care Provider Cover Letter		PDF
		Definitive Medical Report		PDF
	01-04	Irrevocable Assignment of Benefits of Life Insurance /Annuity Policy		PDF
CFS-2017		Fax Cover Sheet to the Attorney General’s Office for Confirmed Findings	DOC
MS-2156	10-01	Medical Review of Emergency Services for Establishing SOBRA Eligibility	DOC	PDF
MS-2126	07-07	Notification of Nursing Facility Admission/Discharge	DOC	PDF
	01-05	OARS Authorization for the Release of Specified Information Which Affects Eligibility for SRS Benefits	DOC	PDF
	01-05	OARS Confidentiality Agreement	DOC	PDF
	01-06	OARS Monthly Status Report Form	DOC	PDF
	08-96	Prior Authorization Form (for purchase > $2,000)		PDF
		Vendor Cover Letter		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	05-92	U.S. Repatriate Program - Privacy Act Statement and Repayment Agreement		PDF

*These forms are available through the SRS Warehouse.

} //--> The Economic and Employment Support Manual 10-08 MISCELLANEOUS FORMS

ADMINISTRATIVE HEARINGS

Item Number

Revised Date

PROGRAM SECTION

File Format

DISABILITY DETERMINATION

Item Number

Revised Date

PROGRAM SECTION

File Format

FRAUD

Item Number

Revised Date

PROGRAM SECTION

File Format

HEALTHWAVE

Item Number

Revised Date

PROGRAM SECTION

File Format

HIPAA

Item Number

Revised Date

PROGRAM SECTION

File Format

HIPPS

Item Number

Revised Date

PROGRAM SECTION

File Format

Integrated Service Delivery

Item Number

Revised Date

PROGRAM SECTION

File Format

MISCELLANEOUS

Item Number

Revised Date

PROGRAM SECTION

File Format

REFUGEE/REPATRIATION PROGRAM

Item Number

Revised Date

PROGRAM SECTION

File Format

The Economic and Employment Support Manual 10-08 MISCELLANEOUS FORMS

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