 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
|
||||||||||||
| |||||||||||||
The following forms are used in the administration of the Special Assistance Program. Refer to http://info.dhhs.state.nc.us/olm/forms/ for copies of the forms.
Form Number |
Effective Date |
Title |
DSS-1473 |
09/99 |
Request for State Appeal |
DSS-1656 |
12/96 |
Refund Receipt (Collection of Overpayment) |
DMA-2041 |
08/98 |
Third Party Health and Accident Resources Information |
DMA-2043 |
01/01 |
Third Party Liability Accident Information Report |
DSS-2216 |
03/01 |
Request for Record |
DSS-3431 |
01/96 |
Request for Financial Information |
DMA-5010 |
07/98 |
Referral for Inpatient Hospital and Intermediate Care Facilities |
DMA-5022 |
12/99 |
Retroactive Eligibility Checks/ID Cards |
DMA-5030 |
07/86 |
Reserve History Sheet |
DMA-5049 |
01/95 |
Referral to SSA |
DMA-5094 |
10/02 |
Notice of Your Right To Apply for Benefits |
DMA-5097 |
10/02 |
Request for Information |
DSS-8108 |
05/99 |
Notice of Benefits |
DSS-8109 |
10/02 |
“Your Application For Benefits Is Being Denied Or Withdrawn” |
DSS-8110 |
10/02 |
“Your Benefits Are Changing” (Timely/Adequate Notice) |
DSS-8113 |
10/98 |
Wage Verification |
DSS-8124 |
01/97 |
Application Data Processing Form |
DSS-8125 |
01/93 |
EIS Data Sheet |
DSS-8126 |
10/90 |
EIS Continuation Sheet |
DSS-8128 |
06/82 |
EIS Possible Duplicate ID Resolution Report |
DSS-8129 |
03/00 |
Request for Replacement Check and Affidavit |
DSS-8131 |
07/97 |
Change in Situation Report |
DSS-8168I |
12/99 |
Lifeline and/or Link-Up |
DSS-8176 |
03/96 |
Contribution Report |
DSS-8189 |
12/99 |
Appointment Notice |
DSS-8190NS |
07/02 |
Special Assistance Workbook for Non-SSI Recipients |
DSS-8190S |
07/02 |
Special Assistance Workbook for SSI Recipients |
DSS-8194 |
07/98 |
Income Maintenance Transmittal Form |
DSS-8213 |
07/96 |
ASAP Workbook |
DSS-8920 |
01/79 |
Forgery Affidavit |
FL-2 |
12/92 |
Level of Care Recommendation |
MR-2 |
01/87 |
Mental Retardation Services |
|
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.
|
|
|
|
|
|
|
|
|
|
|