Free Certification for SSI-E Exceptional Expense Supplement - Wisconsin


File Size: 18.9 kB
Pages: 2
Date: July 31, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 366 Words, 2,698 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20818.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20818 (Rev. 07/2008)

STATE OF WISCONSIN Completion of this form is mandatory per s. 49.77, Wis. Stats.

CERTIFICATION FOR SSI-E EXCEPTIONAL EXPENSE SUPPLEMENT
Personally identifiable information collected on this form is confidential and will be used only to determine eligibility for services and for identification purposes. 2. Type Natural Residential (NR) Substitute Care (SC) 5. Name - Applicant (Last, First, MI) 7. Applicant Address

1. To: State of Wisconsin Department of Health Services P.O. Box 6680 Madison, WI 53716-0680

3. Action Start Stop (decertification-answer question 12)

4. SSI-E Effective Date

/
mo. day

/
full year

6. Social Security Number 8. Date of Birth 9. Telephone Number

/
mo. day

/
full year

12. If STOPPED, Decertification Reason

Date Stopped

10. County of Residence 11. Age/Disability Group Elderly (65+) Physically disabled Alzheimer's/other dementia Developmental disabilities Mental Health AODA

Institutionalized more than 90 days Living arrangement no longer qualifies No longer receives/needs qualifying amount/type of services Death Moved out of state Financially ineligible (for grandfathered individuals) Changed county of responsibility Other--Specify:

I CERTIFY, this information is correct and the action is in accordance with sec. 49.77, Wis. Stats. Re: Federal regulations 20 CFR 416
13. Name ­ Worker 16. SIGNATURE - Agency Director or Designee 18. Agency Name and Address 14. Date Form Completed 15. Worker Telephone Number

17. Name - Representative Payee (if any) 19. Representative Payee Address

20. Date Approved 21. Living Arrangement Upon Certification Foster home for children Group home for children Licensed or certified adult family home CBRF (8 beds or less) CBRF (9-20 beds) CBRF over 20 beds and is a certified independent apartment or w/approved variance Grandfathered CBRF 20 or more beds (Name) Person's own home or apartment Home/apartment of another Other--Specify:

I understand that signing this form means I am applying for the SSI-E Exceptional Expense Supplement.

__________________________________________

__________________________

__________________________________________

SIGNATURE - Applicant/Representative

Application Date

If Representative, Relationship to Applicant

Two Copies:

State of Wisconsin DHS P. O. Box 6680 Madison, WI 53716-0680

One Copy: Applicant

One Copy: Agency Case Record

F-20818 CERTIFICATION FOR SSI-E EXCEPTIONAL EXPENSE SUPPLEMENT

Page 2

ACTION TAKEN SSI-E CERTIFICATION

I have processed this certification. I have not processed this certification. (Reason(s)

SIGNATURE - State SSI Unit Worker

Date Signed