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Fillable Printable Application For Eligibility Determination/Redetermination

Fillable Printable Application For Eligibility Determination/Redetermination

Application For Eligibility Determination/Redetermination

Application For Eligibility Determination/Redetermination

EXHIBIT C2 APPLICATION FOR ELIGIBILITY DETERMINATION (FORM DODD
1014)
The Title XX Application for Eligibility Determination/Redetermination (Form DODD 1014) is required for
documentation of proper intake and determination of services. The form was designed to document
step-by-step the decision process in meeting individual needs in statewide objectives. The form will also
assist agencies in demonstrating a consistent correlation between approved national goals and program
availability to all applicants. Properly maintained individual client records will document the client
eligibility and determination of the appropriate service category (free, for a fee, or without regard to
income). Local agencies that contract with DODD to provide Title XX services are required to maintain
records of program activity in accordance with Section 3.4 of the grant agreement.
**By September 30, 2015 this form should be phased out and replaced by the Certification of Proper
Billing (Form DODD 1014-2)**
Instructions
Section AA must be completed with accurate and current individual information.
Section BB must contain the date of application and document that the individual is eligible for DD
services as determined under OAC 5123:2-1-02. Indicate that the individual has been determined by the
proper local agency to meet the requirements for county board of dd services based upon dd
program(s) as of July 1, 1991. Indicate whether this is an initial application or redetermination of
eligibility.
Section CC must identify the individual’s need as it relates to Title XX services.
Section DD must identify the Title XX specific national goal that addresses the individual’s need.
Section EE must identify the objective of the Title XX service and the corresponding Title XX service
name and billing code.
Section FF must identify the service category under which the provider offers the approved Title XX
services. This category must be stated in the provider Title XX policy and the approved Title XX services
profile for the period.
Section GG must be signed and dated by the individual, legally authorized representative, or head of
household at the time the determination of services is agreed, generally during the service plan
meeting.
The provider must be complete the “For Title XX Provider Only” section. Notification of approval or
disapproval must be indicated with documentation of appeal action attached if necessary. The reviewer
must be indicated with documentation of appeal action attached if necessary. The reviewer must sign
and date the completed form.
Application for Eligibility Determination/Redetermination (DODD 1014)
AA. Client Identifying Information BB. Client Eligibility for CBDD Services
CC. Clients Need (describe briefly)
DD. Program Goal(s) Targeted to Applicant (check one)
___ 1. Self-Support ___ 2. Self-Sufficiency ___ 3a. Protection-Children ___ 3b. Protection-Adult ___ 3c. Preserving Families ___ 4. Community Based Care ___ 5. Institutional Care
EE. Objective of Services (one service per line) Title XX Service Name & 5 Digit Code
FF. Service Category
Income Eligibility:
Fee for Service:
CBDD Rate Schedule or
CDJFS Rate Schedule
Service Included CSSP Profile
Free for Service:
CBDD Rate Schedule or
CDJFS Rate Schedule
Service Included CSSP Profile
Document
Date
Amount indicated on Document
(Write in and check)
Mo
Yr
1. Pay Check Stub
________ Week
$ .00 Per
________ Month
________ Year
2. SSI
________ Week
$ .00 Per
________ Month
________ Year
3. Other - Describe
________ Week
$ .00 Per
________ Month
________ Year
Without Regard to Income:
Service Included CSSP Profile Yes No If no, service cannot be billed to TTXX
GG. Verification
I certify that the information given in this report is accurate, and I will report within two weeks any changes of the above information.
Signature: ___________________________________________________________ Date: ________________________
Client or Authorized Representative or Head of Household
FOR TITLE XX PROVIDER ONLY
Provider name
Provider TTXX Contract No.
Action (Determination required within 30 days. Must provide written notification of decision and applicants right to State Hearing):
Approved; Notice given Disapproved; Form DHS-7334 completed and provided to the applicant
Determination/Redetermination Appealed (Appeal Summary form DHS-4067 attached)
Appeal Approved Appeal Denied
Reviewers Signature: ____________________________________________________________ Date: ________________________
TXX FORM DODD 1014
1. Client Name
1. Date of Application: ___________/__________/_________
2. Eligibility verified from CBDD based upon:
OEDI COEDI Enrolled in CBDD Programs as of 7-1-91
3. Type of Application:
Initial (1
st
time to receive TTXX Services) REDETERMINATION
2. Social Security Number
3. Client Street Address
4. Client City, State, Zip Code
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