What forms do I use in my case setup? Let’s start with the PAFS 116. PAFS 202. Special Case Forms.

1. What forms do I use in my case setup? Let’s start with the PAFS 116. PAFS 202. Special Case Forms. 203 Checklist and forms for client. DCBS Intranet Forms Finish

2. PAFS 116 includes: PAFS 203 PAFS 116, Supplement A PAFS 706 Birth Records Identity Verification Custody, Child Support and Divorce Records DCBS 1 MA 2 Back to Start

3. PAFS 202 includes: KIM 101 (Application) KIM 125 (MSE Referral) PAFS 76 PAFS 700 PAFS 702 PA 33D Back to Start

4. Used to verify HH Comp in E, T, L, N cases. Also used in FS cases to verify Residency, Shelter and Utility Back to 202

5. Verification of Employment and Wages Back to 202

6. Verification of No Income. To be completed by non-household member that knows applicants income situation well. Back to 202

7. Medicaid Penalty Warning; applicant must read and sign. Give client a copy, place original in 116. Back to 116

8. Used to verify full time school attendance for 18-year-olds only in E, T, L, N and Y cases. Back to 202

9. Checklist for Factual information provided to client. Back to 116

10. Used to track time-limited deductions Back to 116

11. PAFS-706 COMMONWEALTH OF KENTUCKY (R. 8/10) Cabinet for Health and Family Services 921 KAR 3:030 Department for Community Based Services Division of Family Support Used for Voter Reg. Rights. Used at every App, ReApp, Recert, Program Transfer and Address Change. VOTER REGISTRATION RIGHTS If you register to vote or decline to register to vote, this decision and any information regarding the office to which the application was submitted remains confidential and is used only for voter registration purposes. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may complete the application form in private, if you desire. If you complete a voter registration application form, it will be forwarded to your local county clerk who will assign you a voting precinct. A confirmation notice with your precinct and voting location will be mailed to you by the county clerk. IF YOU DO NOT RECEIVE SUCH NOTICE WITHIN THREE (3) WEEKS, PLEASE CALL YOUR COUNTY CLERK. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register, or in applying to register to vote, or your right to choose your own political party or other preference, you may file a complaint by writing or calling the State Board of Elections, 140 Walnut Street, Frankfort KY 40601, phone 1-800-246-1399. Please note that KRS 116.045(2) requires the clerk to close all registration 28 days prior to any election. If your application is received during this period, you will not be eligible to vote until the next election. Back to 116

12. Special Case Forms Include:PA 601TMRT 15Back to Start

13. MRT determination referral form for applications. Used with Incapacity Deprivation cases when Field Determination cannot be used. Back to Special Forms

14. Release of info for MRT. Have patient sign one for each provider listed on the 601T and a couple extra, just in case. Send with 601T to the Medical Review Team Back to Special Forms

15. Clients receive these forms:PA 41(Not listed on 203)PAFS 130 (Not listed on 203)MAP 065PA 17CS-333PA 3PAFS 600Civil Rights Pamphlet PA 4 Back to Start

16. PA 41 Health Insurance Letter for any household member that is employed. Must be given at application. Back to Checklist An Equal Opportunity Employer M/F/D

17. Civil Rights Pamphlet Advises all applicants of their civil rights, including their right for a hearing. Back to Checklist

18. HIPAA Information MAP-065 (4/14/03) Cabinet for Health and Family Services Department for Medicaid Services 1 of 6 NOTICE OF PRIVACY PRACTICES WHAT IS THIS NOTICE? This Notice of Privacy Practices is required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This notice tells you: • How the Department for Medicaid Services (DMS) and its contracted business partners may use and give out your protected health information to carry out treatment, payment or health care operations and for other purposes permitted or required by law. • What YOUR rights are regarding the access and control of your Medicaid health information. • How DMS protects your health information. OUR DUTY TO PROTECT YOUR PRIVACY Your health information is personal. DMS is legally required to protect the privacy of your data. It does so in all aspects of its business. DMS has policies about protecting the privacy of your data. These policies comply with State and Federal laws. DMS uses and gives out your health information only where required by law or where necessary for business. WHERE DO I SEND QUESTIONS OR REQUESTS? To submit questions about your privacy rights or to submit a written request to DMS regarding your privacy rights, contact the DMS Privacy Officer at: Cabinet for Health and Family Services Department for Medicaid Services 275 E. Main Street Frankfort KY 40621 Or, you may contact DMS by dialing 1-800-635-2570. If you have a hearing impairment, you may call the TDD/TTY number at 1-800-775-0296. WHAT TYPES OF INFORMATION DOES DMS HAVE? The Department for Community Based Services (DCBS) or Social Security Administration (SSA) for Supplementation Security Income (SSI) approved you for Medicaid. DCBS and SSA send your information to DMS. DMS then pays your provider for claims they send in. Information sent to DMS includes: • Your Individual Information including: name, address, phone number, date of birth, social security number, eligibility program information, Medicaid number. • Information on other health insurance policies you may have THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Back to Checklist

19. CS-333 Facts About The Child Support Enforcement Program. Client signs PAFS 203 to indicate form was provided. Back to Checklist

20. Early and Periodic Screening, Diagnosis and Treatment Services Fact Sheet. Back to Checklist

21. Responsibilities for Reporting Changes. Provide to Client at application, reapplication and recertification, explaining when changes are reported. Back to Checklist

22. Important Information for All Who Apply Information regarding ADA, free interpreter services and disclosure of information. Client signs PAFS 203 checklist indicating form is received. Back to Checklist

23. Consent and Release of Client Information and Records. Used when additional information needs to be obtained from a third party. Back to 116

24. PAFS 600 Fact sheet for Americans with Disabilities Act (ADA) Back to Checklist

25. PAFS 130 Fact sheet used to provide applicant information regarding earned income tax credit. Back to Checklist

26. DCBS FORMS Intranet; forms for family support caseworkers. Next Screen

27. Family Support Forms: Access General Forms Workbook, or scroll page to access Table of Contents for Family Support forms. Comprehensive Table of Contents: Section I Food Stamp Forms Section II Public Assistance/Food Stamp Forms Section III Public Assistance Forms Section IIIA KWP Forms Section IV DCBS Forms Section V Claims/Fraud Forms Section VI Miscellaneous Forms Section VII Publications Section VIII KAMES Forms Section IX Report Series Forms Back to Start

28. Don’t forget: Some local offices use additional forms for case setup. Check with your supervisor regarding your office procedures.You are now ready to continue with assignments under Part I on Blackboard. Back to Start