DHS/SSA Referral Form Instructions and Guidelines
This file provides instructions and guidelines for completing the DHS/SSA Referral Form. It is used to exchange information regarding SSI applicants and recipients, and to determine the level of care for those in need. The form contains multiple sections to be completed by both originating and receiving departments.
Edit, Download, and Sign the DHS/SSA Referral Form Instructions and Guidelines
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out the DHS/SSA Referral Form, you will need to provide detailed information about the individual in question. Ensure all required fields are completed accurately. Follow the specific instructions provided for each section of the form.
How to fill out the DHS/SSA Referral Form Instructions and Guidelines?
1
Enter the name and address of the department to whom the form is being sent.
2
Fill out the name, address, and telephone number of the department sending the form.
3
Include the date and signature of the person sending the form.
4
Identify the person about whom information is being requested or reported.
5
Complete the specific sections relevant to the action being requested.
Who needs the DHS/SSA Referral Form Instructions and Guidelines?
1
Department of Human Services workers needing to refer SSI applicants.
2
Social Security Administration staff exchanging information with DHS.
3
Healthcare providers determining the level of care for recipients.
4
Caseworkers managing supervised placements for state or court wards.
5
Individuals assisting family members with their SSI application process.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the DHS/SSA Referral Form Instructions and Guidelines along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your DHS/SSA Referral Form Instructions and Guidelines online.
With PrintFriendly, you can easily edit the DHS/SSA Referral Form by entering the required information into the PDF editor. Make sure to fill out all the necessary sections accurately. Save and download your edited PDF once you've completed the form.
Add your legally-binding signature.
Sign the DHS/SSA Referral Form on PrintFriendly by using the in-built e-signature feature. Simply click on the signature field, create your e-signature, and place it in the required area. Save the signed document and download it when finished.
Share your form instantly.
Share the DHS/SSA Referral Form on PrintFriendly with ease. After editing and signing the form, you can share the PDF via email directly from the platform. Alternatively, download the form and share it through your preferred method.
How do I edit the DHS/SSA Referral Form Instructions and Guidelines online?
With PrintFriendly, you can easily edit the DHS/SSA Referral Form by entering the required information into the PDF editor. Make sure to fill out all the necessary sections accurately. Save and download your edited PDF once you've completed the form.
1
Open the DHS/SSA Referral Form in the PrintFriendly PDF editor.
2
Enter the required information in the designated fields.
3
Check for accuracy and completeness before proceeding.
4
Save your edited form within the editor.
5
Download the completed form for your records or sharing.
What are the instructions for submitting this form?
Submit the completed DHS/SSA Referral Form to the receiving department specified in the form instructions. Retain a photocopy for your records. Ensure all required fields are completed accurately to avoid delays or non-issuance of public assistance. If the person is an adult, send a photocopy to the local Department of Human Services. For children, send a photocopy to Child and Family Services, Children's Foster Care Program, Department of Human Services, P.O. Box 30037, Lansing, MI 48909. It is recommended to contact the relevant departments for any additional submission requirements.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates in 2024 and 2025 for the DHS/SSA Referral Form.
What is the purpose of this form?
The purpose of the DHS/SSA Referral Form is to facilitate the exchange of information regarding SSI applicants and recipients between various departments and agencies. It helps determine the level of care needed for individuals and provides a structured method for requesting specific actions or information. This form ensures that all necessary details are accurately recorded and shared among relevant parties, aiding in the efficient management of public assistance programs.
Tell me about this form and its components and fields line-by-line.
- 1. Department to Whom the Form is Sent: The name and address of the department receiving the form.
- 2. Department Sending the Form: The name, address, and telephone number of the department sending the form.
- 3. Date and Signature: The date and signature of the person sending the form.
- 4. Person Details: Information identifying the person about whom information is being requested or reported, including name, address, phone number, and Social Security numbers.
- 5. Program Status: The current program status with the originating department of the person about whom information is being requested.
- 6. Action Requested: The specific action being requested, such as the determination of the level of care or other information or actions.
- 7. Authorization of Level of Care: The section where the proper level of care is authorized by the relevant department.
- 8. Other Action Requested: Section to request specific information or actions other than the level of care.
- 9. Information for Use by Receiving Department: Section to inform the receiving department of any relevant information or updates.
- 10. Additional Remarks: Field for adding any additional remarks or comments related to the form.
- 11. Effective Date: The date on which the event or relayed information took place.
- 12. Source: The person or place from whom the originating department got the information.
What happens if I fail to submit this form?
Failure to submit the DHS/SSA Referral Form may result in delays or non-issuance of public assistance. It is crucial to complete and submit the form accurately and on time.
- Delay in Assistance: The processing of public assistance may be delayed if the form is not submitted.
- Non-Issuance of Assistance: Public assistance may not be issued if the form is not submitted.
- Incomplete Records: Failing to submit the form can result in incomplete records and hinder the exchange of necessary information.
How do I know when to use this form?
- 1. SSI Applicant Information: To provide information regarding an SSI applicant or recipient.
- 2. Level of Care Determination: To determine the level of care needed for an individual.
- 3. Requesting Actions or Information: To request specific actions or information from another department.
- 4. Supervised Placements: For managing supervised placements for state or court wards.
- 5. Public Assistance Programs: For the efficient management of public assistance programs.
Frequently Asked Question
What is the DHS/SSA Referral Form?
The DHS/SSA Referral Form is used to exchange information regarding SSI applicants and recipients, including level of care determinations.
How do I fill out the DHS/SSA Referral Form?
Fill out the form by entering the required information in the specified fields, following the provided guidelines and instructions.
Who needs to use the DHS/SSA Referral Form?
DHS workers, SSA staff, healthcare providers, caseworkers, and individuals assisting family members with SSI applications need this form.
Can I edit the DHS/SSA Referral Form on PrintFriendly?
Yes, you can use PrintFriendly's PDF editor to easily fill out and edit the form.
How do I sign the DHS/SSA Referral Form on PrintFriendly?
Use PrintFriendly's e-signature feature to add your signature to the form, then save and download the signed document.
How can I share the DHS/SSA Referral Form on PrintFriendly?
After editing and signing the form, you can share it via email directly from PrintFriendly or download it and share through your preferred method.
What information do I need to provide on the DHS/SSA Referral Form?
You need to provide the name and address of both the originating and receiving departments, the date, relevant identification numbers, and the action being requested.
How do I determine the level of care on the DHS/SSA Referral Form?
Check the appropriate boxes for domiciliary or personal care, and include the necessary facility information and date of placement.
Where do I submit the completed DHS/SSA Referral Form?
Submit the form to the receiving department specified in the form instructions, retaining a photocopy for your records.
Can I use PrintFriendly on any device?
Yes, PrintFriendly is compatible with multiple devices, allowing you to edit, sign, and share your PDF forms on the go.
Related Documents - DHS/SSA Referral Form
DHS HCF Referral Form for Single Adults NYC
The DHS HCF Referral Form must be completed for patients being referred to the DHS Single Adult Shelter or Street System. It helps determine if the patient is medically appropriate for such facilities. Proper completion ensures timely processing and appropriate care.
Form SSA-2853-OP4 Instructions for Social Security
This file provides essential instructions for obtaining a Social Security Card for your newborn. It guides you through the application process and eligibility for Supplemental Security Income for children. Ensure you have all the required information ready to expedite the process.
Social Security Administration Representative Appointment Form
This file is used to appoint a representative to act on your behalf in matters related to Social Security claims. It includes instructions on how to complete the form and information about representation fees. The form must be submitted to the Social Security Administration.
Form SSA-1696 Instructions and Purpose
The Form SSA-1696 is a Social Security Administration document used for appointing a representative for claims and rights. This form outlines the procedures, requirements, and rights of claimants and their representatives. It is essential for those seeking assistance in navigating their Social Security claims.
DHS Forms Management Directive 141-02
This Directive establishes the Department of Homeland Security (DHS) responsibilities and policies for the Forms Management Program. It outlines the scope, authorities, responsibilities, policies, and requirements for the management of forms within DHS. The directive is applicable throughout DHS unless exempt by statute.
DHS Change Report Form Instructions and Details
This file provides essential details for completing the DHS Change Report Form. It outlines necessary sections, instructions, and important information. Use this guide to ensure accurate reporting of changes in your household information.
Metro Referral Associates Customer/Client Referral Form
This form is used by Metro Referral Associates to facilitate the referral of clients or customers between agents. It includes sections for detailed client information, property details, and acceptance conditions. Fill out the required fields to ensure proper processing and acceptance of referrals.
Michigan DHS Verification of Employment Form
This form is used by the Michigan Department of Human Services to verify employment status, income, and benefits. It is vital for ensuring accurate eligibility for services. Employers must complete and return the form by the specified date.
Form SSA-8150-EV - Reporting Events - SSI Changes
This file is used to report changes in circumstances that may affect Supplemental Security Income (SSI) payments. It includes fields for changes in address, income, and other relevant information. The form must be filled out accurately to ensure correct SSI payments.
