DHS/SSA Referral Form Instructions and Guidelines
This file provides instructions and guidelines for completing the DHS/SSA Referral Form. It is used to exchange information regarding SSI applicants and recipients, and to determine the level of care for those in need. The form contains multiple sections to be completed by both originating and receiving departments.
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How do I fill this out?
To fill out the DHS/SSA Referral Form, you will need to provide detailed information about the individual in question. Ensure all required fields are completed accurately. Follow the specific instructions provided for each section of the form.
How to fill out the DHS/SSA Referral Form Instructions and Guidelines?
1
Enter the name and address of the department to whom the form is being sent.
2
Fill out the name, address, and telephone number of the department sending the form.
3
Include the date and signature of the person sending the form.
4
Identify the person about whom information is being requested or reported.
5
Complete the specific sections relevant to the action being requested.
Who needs the DHS/SSA Referral Form Instructions and Guidelines?
1
Department of Human Services workers needing to refer SSI applicants.
2
Social Security Administration staff exchanging information with DHS.
3
Healthcare providers determining the level of care for recipients.
4
Caseworkers managing supervised placements for state or court wards.
5
Individuals assisting family members with their SSI application process.
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What are the instructions for submitting this form?
Submit the completed DHS/SSA Referral Form to the receiving department specified in the form instructions. Retain a photocopy for your records. Ensure all required fields are completed accurately to avoid delays or non-issuance of public assistance. If the person is an adult, send a photocopy to the local Department of Human Services. For children, send a photocopy to Child and Family Services, Children's Foster Care Program, Department of Human Services, P.O. Box 30037, Lansing, MI 48909. It is recommended to contact the relevant departments for any additional submission requirements.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates in 2024 and 2025 for the DHS/SSA Referral Form.
What is the purpose of this form?
The purpose of the DHS/SSA Referral Form is to facilitate the exchange of information regarding SSI applicants and recipients between various departments and agencies. It helps determine the level of care needed for individuals and provides a structured method for requesting specific actions or information. This form ensures that all necessary details are accurately recorded and shared among relevant parties, aiding in the efficient management of public assistance programs.
Tell me about this form and its components and fields line-by-line.
- 1. Department to Whom the Form is Sent: The name and address of the department receiving the form.
- 2. Department Sending the Form: The name, address, and telephone number of the department sending the form.
- 3. Date and Signature: The date and signature of the person sending the form.
- 4. Person Details: Information identifying the person about whom information is being requested or reported, including name, address, phone number, and Social Security numbers.
- 5. Program Status: The current program status with the originating department of the person about whom information is being requested.
- 6. Action Requested: The specific action being requested, such as the determination of the level of care or other information or actions.
- 7. Authorization of Level of Care: The section where the proper level of care is authorized by the relevant department.
- 8. Other Action Requested: Section to request specific information or actions other than the level of care.
- 9. Information for Use by Receiving Department: Section to inform the receiving department of any relevant information or updates.
- 10. Additional Remarks: Field for adding any additional remarks or comments related to the form.
- 11. Effective Date: The date on which the event or relayed information took place.
- 12. Source: The person or place from whom the originating department got the information.
What happens if I fail to submit this form?
Failure to submit the DHS/SSA Referral Form may result in delays or non-issuance of public assistance. It is crucial to complete and submit the form accurately and on time.
- Delay in Assistance: The processing of public assistance may be delayed if the form is not submitted.
- Non-Issuance of Assistance: Public assistance may not be issued if the form is not submitted.
- Incomplete Records: Failing to submit the form can result in incomplete records and hinder the exchange of necessary information.
How do I know when to use this form?
- 1. SSI Applicant Information: To provide information regarding an SSI applicant or recipient.
- 2. Level of Care Determination: To determine the level of care needed for an individual.
- 3. Requesting Actions or Information: To request specific actions or information from another department.
- 4. Supervised Placements: For managing supervised placements for state or court wards.
- 5. Public Assistance Programs: For the efficient management of public assistance programs.
Frequently Asked Questions
What is the DHS/SSA Referral Form?
The DHS/SSA Referral Form is used to exchange information regarding SSI applicants and recipients, including level of care determinations.
How do I fill out the DHS/SSA Referral Form?
Fill out the form by entering the required information in the specified fields, following the provided guidelines and instructions.
Who needs to use the DHS/SSA Referral Form?
DHS workers, SSA staff, healthcare providers, caseworkers, and individuals assisting family members with SSI applications need this form.
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What information do I need to provide on the DHS/SSA Referral Form?
You need to provide the name and address of both the originating and receiving departments, the date, relevant identification numbers, and the action being requested.
How do I determine the level of care on the DHS/SSA Referral Form?
Check the appropriate boxes for domiciliary or personal care, and include the necessary facility information and date of placement.
Where do I submit the completed DHS/SSA Referral Form?
Submit the form to the receiving department specified in the form instructions, retaining a photocopy for your records.
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