Ohio Residential State Supplement Living Arrangement Form Q3 2022
This document is the Ohio Residential State Supplement (RSS) Living Arrangement Form for Quarter 3, January 2022 to March 2022. It must be completed to confirm living arrangements for individuals enrolled in RSS. The information provided should be as of January 1, 2022, and the form should be returned by February 1, 2022.
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How do I fill this out?
To fill out the RSS Living Arrangement Form, you will need to provide specific details about your licensed facility and the individuals residing there as of January 1, 2022. Ensure all information is accurate and complete before submission. Follow the detailed instructions provided in each section of the form.
How to fill out the Ohio Residential State Supplement Living Arrangement Form Q3 2022?
1
Enter the residential facility name, operator name, address, county, and license number.
2
Confirm the residents listed in Table 1 and mark them as Current Resident or No Longer a Resident.
3
Provide information for new residents not listed in Table 1 in Table 2.
4
List individuals who moved out by January 1, 2022, in Table 3 along with their new address if known.
5
Sign and date the form, then submit it via encrypted email, fax, or mail by February 1, 2022.
Who needs the Ohio Residential State Supplement Living Arrangement Form Q3 2022?
1
Licensed residential facility operators in Ohio providing living arrangements for RSS enrollees.
2
Individuals managing facilities that require quarterly confirmation of RSS eligibility.
3
State officials verifying compliance with Ohio Administrative Code 5122-36-04.
4
Accountants or administrative staff responsible for completing state supplement forms.
5
Legal representatives ensuring accurate and up-to-date information is reported.
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1
Upload the RSS Living Arrangement Form to PrintFriendly.
2
Select the text fields you need to edit and enter the correct information.
3
Use checkboxes to indicate residents' status in Tables 1 and 2.
4
Add any additional required information in Table 3.
5
Save and download the edited PDF for submission.
What are the instructions for submitting this form?
Submit the completed RSS Living Arrangement Form to Community Transitions via encrypted email to RSSverify@mha.ohio.gov or fax to 614-485-9747. The form must be submitted by February 1, 2022. Ensure all information is accurate and complete before submission. My advice is to double-check all entries and maintain a copy for your records.
What are the important dates for this form in 2024 and 2025?
The important dates for the RSS Living Arrangement Form in 2024 and 2025 are the start of each quarter and the submission deadlines. Ensure to submit the forms by February 1, May 1, August 1, and November 1 of each respective year.
What is the purpose of this form?
The purpose of the RSS Living Arrangement Form is to confirm the living arrangements of individuals enrolled in the Ohio Residential State Supplement (RSS) Program. This form must be completed each quarter to ensure compliance with state regulations and to verify that the facility continues to be eligible for the RSS Program. Providing accurate information helps maintain the integrity of the program and ensures that residents receive the appropriate support.
Tell me about this form and its components and fields line-by-line.
- 1. Residential Facility Name: The name of the licensed residential facility.
- 2. Operator Name: The name of the facility operator.
- 3. Residential Facility Address: The physical address of the residential facility.
- 4. Residential Facility County: The county where the residential facility is located.
- 5. Facility License #: The unique license number of the facility.
- 6. # of Licensed Beds: The total number of licensed beds in the facility.
- 7. Operator Contact Phone: The contact phone number for the facility operator, including area code.
- 8. Operator Contact Email: The contact email address for the facility operator.
- 9. Table 1: A table to confirm the residents listed as enrolled in the RSS Program.
- 10. Table 2: A table to provide information for new residents not listed in Table 1.
- 11. Table 3: A table to list individuals who moved out by January 1, 2022, along with their new address if known.
- 12. RSS Living Arrangement Form Mailing Address: The address where the completed form should be sent.
- 13. Operator Printed Name, Signature, Date: Fields for the operator's printed name, signature, and the date of signing.
What happens if I fail to submit this form?
If you fail to submit the RSS Living Arrangement Form by the deadline, your facility may lose its eligibility for the RSS Program. This can impact the support and services provided to residents.
- Ineligibility for RSS Program: Failing to submit the form may result in your facility being ineligible for the RSS Program.
- Loss of Support: Residents may lose access to support services provided under the RSS Program.
- Regulatory Compliance Issues: Non-submission can lead to compliance issues with state regulations and potential penalties.
How do I know when to use this form?
- 1. Quarterly Reporting: Submit the form every quarter to maintain compliance with RSS Program requirements.
- 2. Confirming Resident Status: Use the form to confirm the current resident status of individuals in your facility.
- 3. Updating Resident Information: Provide updates on new residents and those who have moved out.
Frequently Asked Question
What is the RSS Living Arrangement Form?
The RSS Living Arrangement Form is used to confirm the living arrangements of individuals enrolled in the Ohio Residential State Supplement (RSS) Program.
Who needs to fill out this form?
Licensed residential facility operators in Ohio managing RSS enrollees must fill out this form quarterly.
What information is required?
Details about the facility, resident status, move-in and move-out dates, and operator contact information are required.
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Upload the form to PrintFriendly, make the necessary changes using our PDF editor, save your edits, and download the updated PDF.
Can I sign the form electronically?
Yes, PrintFriendly provides an e-signature tool for you to sign the form electronically.
How do I submit the form?
Submit the completed form via encrypted email, fax, or mail by February 1, 2022.
What happens if the form is not submitted on time?
Failure to submit the form on time may result in the facility being ineligible for the RSS Program.
Where can I find the deadline for submission?
The deadline for submission is specified on the form and is February 1, 2022.
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