Below is a list of a variety of DPA forms that have been revised and/or distributed over the course of the last month. Forms can be ordered by following the instructions on DPAweb (How To Order Forms) and can also be obtained from the e-forms website.
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Form Number/Name
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Reason for Change
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Implementation
Instructions
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Effective Date
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Med 2, Authorization for Release of Protected Health
Information
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As a result of concerns
expressed by Medical Providers, additional HIPAA language has been added to
facilitate the completion of DDS decisions and case processing.
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Immediately begin using
this form by printing copies from the e-forms website. If you provide the
Med 2 to any care coordinators or partner agencies, please distribute the new
version to them.
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Begin using the revised
Med 2 form immediately.
Please discard any stock
you have of the old version of this form.
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TA 2, Family Self-Sufficiency Plan and TA 2a, Family
Self-Sufficiency Plan Attachment
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Revised to include changes
announced on 1/27/04 regarding the enhanced version available in CMS and EIS
on 2/2/2004.
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These forms will be
available for use by case managers in CMS, and viewing by other staff in EIS
effective 2/2/2004. They will also be posted on the e-forms website.
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February 2, 2004.
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Gen 51, Rights and Responsibilities
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Incorporates information
about the new food stamp semi-annual reporting requirements.
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A supply of this form was
mailed to DPA field offices January 22. Please discard old versions of the
Gen 51 and begin using the new one when the forms are received.
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Begin using the revised
Gen 51 when the supply is received.
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Gen 50B Application for Services
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Includes the new Gen 51
that incorporates information about the food stamp semi-annual reporting
requirements.
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A
supply was printed and mailed to all DPA offices the week of January 20th.
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Prior versions of the
application can still be used until the stock is exhausted.
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Gen 72, Eligibility Review Form
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Re-formatted the last page
and added the new Gen 51, which includes information about the food stamp
semi-annual reporting requirements
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This version was included
in the mailing to households needing to review or recertify in February. A
supply of the revised form will be distributed to offices soon.
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Prior versions of the Gen
72 can continue to be used until stock is exhausted.
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Gen 55, Change Report Form
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Incorporates information
about the new food stamp semi-annual reporting requirements
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Now being printed for
distribution to offices next week. It will also be available on the e-forms
website.
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Please
use the new Gen 55 form and discard older versions when you receive the new
supply.
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Gen 93, Reporting Changes
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Incorporates information
about the new food stamp semi-annual reporting requirements, and provides the
different program reporting requirements in a matrix format.
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This tool can be used to
help explain the reporting requirements for the different programs. A supply
is being printed and will be distributed to DPA offices soon. The brochure
will also be available on the e-forms website.
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Please
discard previous versions of the Gen 93 and begin using the new version when
the supply is received.
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