The following is a list and description of the forms most commonly used by IMA. The first set of forms are those which do not have form numbers; these forms are referred to by name or title. The second set of forms are those which have form numbers.

 

ACEDS Verification Checklist - document that informs an applicant what information is needed to determine program eligibility. All applicants from whom information is needed must be given a checklist. If the system is inoperable, issue a 1356 Manual Application Checklist. Original to applicant/recipient, copy in record.
  
Acknowledgment of Paternity - form completed by a father whose name does not appear on the birth certificate (or whose name is on a D.C. birth certificate issued prior to 10/81, but the father was not married to the mother and there has been no adjudication) to establish that the individual is, in fact, the father of the child. Original to CSED, copy in record, copy to father, copy to mother.

 

Combined Application (aka Generic Application, English*/Spanish*) - application used for TANF, GC, IDA, and FS

 

DC Healthy Families Application (English*/Spanish*) - Medicaid application used by families with children.

 

EBT Referral - form completed by SSR to reinstate benefits for a recipient whose EBT account has been closed due to inactivity. Original faxed and filed in case record.

 

Food Stamp Expense Addendum to Generic Application - form completed at application and recertification explaining that dependent and shelter care expenses will not be considered if verification is not provided.

 

Food Stamp Only Application - application usable for Food Stamps only

 

Generic Application (aka Combined Application) - application used for TANF, GC, IDA and FS.

 

Generic Recertification Form - form used to recertify TANF, GC and FS.

 

Immigration and Citizenship Initial Declaration Form - an initial form used to determine household members who are US citizens, nationals or "qualified" immigrants.
  
IV-D Partnership Agreement - form used to notify TANF and Medicaid customers of child support requirements and the good cause reasons for non-cooperation.

 

Notice of Privacy Practices (English*/Spanish*) - form used to notify Medicaid/Medical Assistance customers of their rights pertaining to the release of protected health information and other personal data.

 

Periodic Report - form completed quarterly by employed TANF recipients to report earnings and certain household changes.

 

Preliminary Assessment - form completed by SSR and TANF applicant to assess his/her employability. Original forwarded, copy in record, copy to applicant/recipient.

 

Rental Vendor Referral Form - form used to refer a TANF applicant/recipient for rental vendor payment.  Original forwarded, copy in record.
    
Report of  Non-Compliance with TANF Requirements - form issued by TANF operations unit to report non-compliance with TANF work requirements.

 

TANF Work Activity Referral - form used to refer mandatory and voluntary applicants/recipients to Job Club, Teen Parent program, and Negotiated Suitability Training (for those interested in self-initiated training).  The referral form can also be used to refer applicants/recipients who need child care assistance to the Office of Early Childhood Development. Original forwarded, copy in record, copy to customer.

 

Token Receipt Form - form completed by SSR authorizing bus tokens.  Original to customer, copy in record, copy to TANF operations unit.

 

Voter Registration Agency Certification - form completed by recipient when a household's address changes or a voting-age adult is added to the unit indicating whether the recipient would like to obtain a voter registration form. Original in record.

 

FSET-1	Food Stamp Registration for Employment and Training Services - form completed at application and annually thereafter by FS recipients mandated to work register. The form serves as the work registration and the referral form to the FSET program. Original to FSET, copy in record.
FSET-3	Report of Non-Compliance - form sent to SSR by FSET to report recipient's non-compliance with FSET requirements.
1-2140	Spend-down Tracking Form - form sent to the Medical Assistance Administration so that medical bills are paid for spend-down customers. Original forwarded to MAA, copy in record.
26	Expedite Form - form required at application and recertification to determine if applicant/recipient is eligible for expedited food stamp service.  While required at recertification, individuals recertifying FS eligibility that have experienced no break or lapse in benefits are ineligible for expedited processing.  Original in record, copy to applicant/recipient.
30A	Medical Assistance Data Entry Form - form that indicates Medicaid eligibility period for spend-down, YSA, CFSA, and other customers. Original in record.
30-AW	Medical Assistance Data Entry Form - form that indicates Medicaid eligibility period for Medicaid Waiver and Demonstration customers. Original in record.
107	Request for BMS Investigation - form used to request an investigation from the Office of Quality Assurance & Analysis (formerly known as the Bureau of  Management Systems).  Original to OQAA, copy in record.
107	Verification of  Residence - form that can be used to verify residence.
107	Verification of  Employment - form that can be used to verify employment and earnings.
107	Verification of Child Care - form that can be used to verify child care expenses.
107	Verification of  Household Composition - form that can be used to verify household membership.
107	Financial Verification Statement - form that can be used to verify income.
107	Referral to APRA/POWER - form used to refer POWER recipients to the Addiction Prevention and Rehabilitation Administration for substance abuse treatment or counseling.  Original to recipient, copy in record.
107	Referral to RSA/POWER - form used to refer POWER recipients to the  Rehabilitation Services Administration.  Original to recipient, copy in record.
107	Referral for Domestic Violence Services - form used to refer TANF applicant/recipient to the Domestic Violence Unit.
FNS 387	Food Stamp Change Report Form - form given to applicant/recipient to report interim changes to the Agency. Forms submitted by the recipient to report a change are kept in the case record.
495	Authorization for Investigation - form signed by applicants to authorize the agency to seek information from collateral contracts. Required for all MA, TANF, GC and FS cases  (except by those applicants/recipients who use the DC Healthy Families application). Original and copy in record.
495-ARI*	Release of Information* - form used by the customer to authorize the release of information, included protected health information to a third party.
496-COA	Change of Address - form used by Medicaid/Medical Assistance customers to report change of address.
726	Report of Overpayment - form used to report TANF overpayments to OIC and identify amount to be recouped. Original to recipient, copy in record, copy to Special Services.
854	Social Information-Medical Review - form completed by MA and TANF applicant/recipient and their SSR to determine incapacitation/disability in cases in which the applicant/recipient claims to be disabled or incapacitated. Original to MRT, copy in record.
856*	Medical Examination Report* - form completed by applicant's/recipient's physician which is used to determine incapacitation/disability. Original to MRT, copy in record.
886	Information Exchange - form used when there is formal exchange of information within IMA or between IMA and other DC government entities. Original forwarded, copy in record.
886-Waiver	Notification of New Medicaid Waiver Case - form used by the Medicaid Branch to communicate to SSRs in a Service Center that one of their current customers has enrolled in a Medicaid Waiver program.
886-Ward*	Notification of District Ward Status* - form used by the Medicaid Branch to communicate to SSRs in a Service Center that one of their current customers has been declared to be a ward of the District.
1016	Verification of Marriage - form used to verify marriage.
1020	Referral to Medical Review Team - cover sheet for submitting the medical packet to MRT. Original forwarded, copy in record.
1049	Verification of Vital Event - form used for confirmation of birth or death in the District of Columbia.
1052	Record of Case Action - dictation sheet for case actions that is kept in the case record.
1209	Medicaid Recertification Form (English*/Spanish*) - form used to redetermine Medicaid eligibility for non-TANF MA cases.
1209 W	Medicaid Recertification Form - form used by District agencies to report Medicaid eligibility recertification information for customers enrolled in Medicaid Waivers and Demonstrations.
1210*	Medicaid Recertification Worksheet* - form used to determine the appropriate procedure for processing a Medicaid recertification form that is returned by the customer.
1288/A	Notice To Child Support Agency - form used to report information about absent parent(s) to the Child Support Enforcement Division (CSED). Original plus one copy to IV-D and copy in record.
1348	Request for a Fair Hearing - form completed by applicant/recipient or Agency representative to report request for a fair hearing. Original forwarded, copy in record.
1356	Manual Application Checklist - form used to request information needed to determine program eligibility from applicants when ACEDS is inoperable. Original to applicants, copy in record.
1400*	Notice to Applicants*  - form that notifies applicants of their rights. Original to applicant, copy in record.
1503	Redetermination of Eligibility - form generally used to schedule a TANF review. Form can also be used to gather additional needed information from applicants/recipients in any IMA program.  Original to applicant/recipient, copy in record.
1549	Verification of School Attendance - form required for all TANF children 16 years of age and older to verify that a minor child is enrolled and/or attending school. This form can also be used to verify "Living With" and residency. Returned form is kept in case record.
1673A	Insurance Reporting Form (Third Party Liability) - form used to notify the Medical Assistance Administration of private health insurance coverage. Information must be entered on ACEDS "HEIC" screen. Original forwarded, copy in record.
1673B	Notice of Potential Medicaid Payment Recovery - form used to report potential resources such as lawsuit or workman's compensation to MAA. Original forwarded, copy in record.
1692	Countable Medical Expenses - form lists medical expenses incurred during the six month prospective period for spend-down cases. Original in record.
1693	Spend-down Worksheet - form used to compute periods of Medicaid eligibility under spend-down provisions. Original in record.
1747	Food Stamp Claims Report - forms used to report FS overpayment.  Original plus one copy along with verification is sent to FS Special Services Unit. Copy kept in case record
1779	Referral for Photo ID - form used to refer those FS applicants/recipients who have no official form of identification.
1926	Citizenship/Alienage Declaration - addendum used at application to ascertain citizenship and/or immigration status. When adding a person to the assistance unit, use a new addendum.
1934	Notice of Presumptive Eligibility Determination - form completed by agency to notify applicant/recipients of eligibility for presumptive eligibility for ambulatory prenatal care.  Original to customer, copy in record.
1935	Presumptive Eligibility Determination Form - form completed by customer to determine eligibility for presumptive eligibility prenatal services. Original in record.