Transcript FSEP DCBS Forms - DCBS Training Branch

FSEP Guide
DCBS forms for a Family
Support Caseworker
Click Here
to Begin
What forms do I use in my
case setup?
Let’s start with the 116.
Let’s start with the 202.
Special Case Forms.
203 Checklist and forms for client.
DCBS Intranet Forms
Finish
PAFS 116 includes:
PAFS 203
PAFS 706
Birth Records
Identity Verification
Custody, Child Support and
Divorce Records
DCBS 1
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PAFS 202 includes:
KIM 101 (Application)
FS 8
PAFS 19
PAFS 121
FS 704
PAFS 76
PAFS 700
PAFS 702
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Department for Community Based Services
PAFS-76
(R. 6/08)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
FMTL-403
Information Request
Return to:
Case Name: ___________________________
Case Number:__________________________
K-TAP
App.
FS
Recert
JT
Change
MA
Worker Name/Code: ______________________
Address: _______________________________
_______________________________
Phone #: _______________________________
Date: _______________________________
We need to verify information about the person named above. He/She has applied for, or is receiving benefits from state
programs and has given your name as a person we can contact who is familiar with his/her situation. Please return to the worker
above once completed. Use the back of this form if you need more room for any additional information.
Used to verify
Residency,
Household
composition,
Shelter and
Utility
expenses
Residency
What is this person's address (including county) and phone #? _____________________________________________
(Address where this person lives [not mailing address])
__________________________, ________ ___________
(City)
(State)
(Zip)
__________________,
_________________________.
(County)
(Phone #)
Household Composition
List everyone who lives at this address.
Are you related to a household member?
Yes
No
Utilities
Does he/she pay out-of-pocket money for heating or air conditioning?
Yes
No
Does he/she pay out-of-pocket money for utility expenses other than heating or air conditioning?
Are you the manager/landlord?
Yes
Yes
No
No If no, do not complete the landlord section.
For Landlords Only
Does this person rent?
Yes
No How much does he/she pay per
week or
month?
Does this person work in exchange for rent instead of paying?
Yes
No If yes, how many hours per week?
Is the rent paid by, or in part by, anyone other than the person listed above?
Yes
No
If yes, who?
HUD Section 8,
Other agency,
Other person__________________________.
How much is paid per
week or month? $_______________
Is the check payable only to the
recipient,
landlord, or
both?
Are utilities included in the rent?
Yes
No
If no, are utilities billed to the recipient?
Yes
No
Unknown.
Does HUD Section 8 or any other agency pay all or part of the utilities?
Yes
No If yes, how much? $_________
Did this person receive a Home Energy Assistance Program (HEAP) payment for the above listed address?
Yes
Is utility payment deducted from rent?
Yes
No If yes, total tenant payment. $___________________
No
Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties
provided by state and federal law, including fines, imprisonment or both.
I,
(Please print your name)
, certify that the information contained in this form is true and correct to the best of my
knowledge.
KentuckyUnbridledSpirit.com
An Equal Opportunity Employer M/F/D
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202 Click
Here
PAFS-19
(R. 11/07)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
FMTL-397
CHILD CARE VERIFICATION
Case Name _________________________ Worker _______________________ Date _________________
Case Number ___________________________ Worker Phone Number _____________________________
Child Care
Verification
Form
____________________________________________ has reported that you provide child care services.
Please complete the following. Do not include any amounts charged for kindergarten. Kindergarten expenses
are not allowed as dependent care expenses. If childcare is provided for these children after school hours,
please include the cost of after school care.
Date Began __________________ Day of Week Paid ___________________ Rate Per Child _____________
Paid: Weekly _________ Every Two Weeks __________ Twice a Month ___________ Monthly ___________
Please list payments received for each child during the month of _______________ through ______________
____________________________ ____________________________ _____________________________
Child's Name
Child's Name
Child's Name
Date
Received
Amount
Date
Received
Amount
Date
Received
Amount
1.
2.
3.
4.
5.
6.
7.
8.
Child Care Provider Signature _____________________________ Date ____________ SSN_____________
Day Care Facility Name ____________________________________ Phone Number___________________
Address ___________________________________ City __________________ State _______ ZIP________
“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human
Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex,
age or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion
or political beliefs.”
“To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).
Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or
call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.”
YOU MAY ALSO FILE YOUR COMPLAINT WITH THE CABINET FOR HEALTH AND FAMILY SERVICES, OFFICE OF
HUMAN RESOURCE MANAGEMENT, EEO COMPLIANCE BRANCH, 275 EAST MAIN STREET, 5C-D, FRANKFORT,
KENTUCKY 40621 OR CALL (502) 564-7770 EXT. 4107.
IF YOU HAVE COMPLAINTS ABOUT YOUR CASE, YOU CAN CALL THE OMBUDSMAN'S OFFICE AT 1-800-372-2973. TTY
IS AVAILABLE AT 1-800-627-4702.
KentuckyUnbridledSpirit.com
An Equal Opportunity Employer M/F/D
Back to 202
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Statement of
Disability or
Incapacity.
Not used for
incapacity
Medicaid
cases.
Back to 202
Click Here
Student
Income
Verification
Form
Completed by
Financial Aid
Office
Back to 202
Click Here
Irregular
Work Form
Used with
Odd Job and
Seasonal
Employment
Back to
202
Click Here
PAFS-700
(R. 11 /08)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
Date______________________
Type of Action
APP
RECERT
CHANGE
Case Name ___________________________________________________________ Case Number ______________________
Verification of
Employment
and Wages
VERIFICATION OF EMPLOYMENT AND WAGES
Return to: Worker Name/Code _________________________________________________________ Phone ______________________________
Address ___________________________________________________________________________ Fax ________________________________
Employer_______________________________________________________________________________________________________________
Please provide the following information from your records for ______________________________________________________________________
(Employee Name)
(SSN)
1. Employee Name and/or SSN (if different) ____________________________________________________________________________________
2. Is this person currently employed by you?
Yes
No
3. Date of most recent hiring _______________________
(Employee Name)
(SSN)
Date first paid ________________________
4. Hourly Pay Rate _________ Overtime Rate________ Anticipated Hours per Week_______ Day of Week Paid___________ Shift Premium _______
5. Is the employee's share of taxes deducted from gross wages?
Yes
No
6. Is the employee’s hourly Pay Rate scheduled to change?
Yes
No If yes, the Pay Rate will change to ___________________beginning on
______________________ and will be reflected in the check the employee will receive on _________________________.
7. If the hours listed above have changed, give the normal work hours and date changed: Hrs. ______________
8. Did the employee voluntarily reduce work hours?
9. Are wages paid
weekly,
every two weeks,
Date_________________
Yes
No If yes, reason ___________________________________________________.
twice a month,
monthly,
other _________?
10. Are wages paid through Title V, Older Americans Act
Yes
No
WIA
Yes
No
OR
Both
Yes
No?
11. List the wages that have been paid during the months of ______________________________ through __________________________________.
Date
Received
Hours
Gross
Wages
*Tips
**Earned
Income Tax
Credit (EIC)
Taxes
Withheld
Date
Received
1.
6.
2.
7.
3.
8.
4.
9.
Hours
Gross
Wages
*Tips
**Earned
Income Tax
Credit (EIC)
Taxes
Withheld
5.
10.
*Report separately if not included in gross wages. **Report the amount of the EIC payment separately. Do not include EIC in gross wages.
12. Has this employee ever filed a Worker's Compensation Claim?
Yes
No
Date_______________________
13. Is this employee participating in a company retirement plan?
Yes
No Type of Plan ______________________ Balance of Fund __________
Is there a penalty for early withdrawal?
Yes
No If yes, what is the amount of the penalty?_____________________
Termination Status:
Fired
Quit
Other
Date __________________
Reason___________________________________________________________________________________________________________________
Date final check received or expected ___________ Gross Amount _______________ Vacation/Sick Pay: Date ___________ Amount ____________
Employer/Business Name____________________________________________________________________________________________________
Please list name, address and telephone number of the company through which payroll is issued, if different.
Name______________________________________________________________________________Phone_________________________________
Address____________________________________________________ City_____________________________ State__________ Zip___________
Department for Community Based Services
Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties provided by state and
federal law, including fines, imprisonment or both.
I certify that the information contained in this form is true and correct to the best of my knowledge.
Signature _________________________________________________ Title _____________________________________ Date
________________
Print Name____________________________________________________________________________ Phone ______________________________
Address_____________________________________________________City______________________________ State_______ Zip ____________
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PAFS-702
(R. 9/09)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
Department for Community Based Services
PROOF OF NO INCOME
Date issued:
Case Name:
Case SSN:
To client:
Have an individual who knows your situation well and is not a member of your food
benefits household; complete this form to verify you have no income.
To the individual:
Complete this form if you can certify the individual’s income situation.
I certify that to the best of my knowledge and belief ______________________________
has had or will have no income from any source during the following month(s):
____________________, ____________________, and ___________________.
Warning: Any person who aids another person to obtain assistance (or benefits)
fraudulently is subject to penalties provided by state and federal law, including
fines, imprisonment or both.
I certify that the information contained in this form is true and correct to the best of my
knowledge.
Verification of
No Income.
To be
completed by
non-member
that knows
applicants
income
situation
well.
Signature _________________________________________________________________
Print name here
________________________________________________________________________
Date ________________
Phone ___________________________
Address__________________________________________________________________
City ________________________________________________________
State _______ Zip ___________
Return to ______________________________________________, Worker
Address ______________________________________________
City __________________________ State ______________ Zip ________
Telephone number ________________________________
Back to 202
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PAFS-203
(R. 1/09)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
CHECKLIST OF FACTUAL INFORMATION PROVIDED
Case Name: _______________________________________
Case Number: __________________
Type of Case:
FS
Program Code ___________
Type of Action:
Application
K-TAP
MA
Recertification
Case Change/Member Add
All Program Applications
PAFS-4, Important Information for All Who Apply
Checklist for
Factual
information
provided to
client.
Civil Rights Pamphlet
PAFS-600, Do You Know? (ADA)
Food Benefits
FS-120, Information Needed to Process a Food Stamp Application
FS-360, Facts about Food Stamps
FS-500.1, Able-Bodied Adults without Dependents Fact Sheet
FSET-101, Food Stamp Employment and Training Program Fact Sheet
K-TAP and Medicaid
CS-333, Facts about the Child Support Enforcement Program
MAP-065, Kentucky Department for Medicaid Services Notice of Privacy Practices
PA-3, Facts about the EPDST Services
PA-17, Responsibilities for Reporting Changes
Medicaid (HCBS, SCL, ICF/MR/DD, LTC)
MAP-708, Fact Sheet Medicaid Estate Recovery
K-TAP
PA-33E, Overview of the PA-33 Process
PA-90, K-TAP Lump Sum Income Fact Sheet
PA-219, Kentucky Works Assessment Process
I have received the forms marked above. My worker has explained the information and answered my
questions about the information.
___
(Signature)
_______
__________
(Date)
KentuckyUnbridledSpirit.com
__________
(Worker Init.)
An Equal Opportunity Employer M/F/D
Page 1 of 1
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PAFS-706
(R. 8/08)
921 KAR 3:030
Division of Family Support
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
VOTER REGISTRATION RIGHTS AND DECLINATION
___________________________________
(Applicant or Recipient Name)
___________________________________
(Case Name)
___________________________________
(Applicant or Recipient SSN)
___________________________________
(Case Number)
PART I. RIGHTS

APPLYING TO REGISTER OR DECLINING TO REGISTER TO VOTE DOES NOT AFFECT THE AMOUNT OF
ASSISTANCE THAT YOU MAY BE OR ARE PROVIDED BY THIS AGENCY.

If you register to vote or decline to register to vote, this decision and any information regarding the office to which
the application was submitted remains confidential and is used only for voter registration purposes.

If you would like help filling out the voter registration application form, we will help you.
seek or accept help is yours. You may complete the application form in private.

If you complete a voter registration application, the voter registration application will be forwarded to your local
county clerk. The county clerk will assign you a voting precinct. A confirmation notice with your precinct name
and voting location will be mailed to you by the county clerk. If you do not receive this notice within three weeks,
please contact your county clerk.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to
privacy in deciding whether to register, your right in applying to register to vote, or your right to choose your own
political party or other political preference, you may file a complaint by calling 1-800-246-1399.
Used for
Voter Reg.
Rights &
Declination
The decision whether to
I have read, or have had read to me my rights concerning registering to vote.
I understand these rights.
I
authorize the Department for Community Based Services to release information concerning voter registration to
the Kentucky Board of Elections and the County Court Clerks.
In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and
Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national
origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the
basis of religion or political beliefs.
To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).
Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201
or call (202) 619-0403 (voice) or (202) 619-3257 (TTY).
USDA and HHS are equal opportunity providers and
employers.
Will NOT
change the
applicants
eligibility
YOU MAY ALSO FILE YOUR COMPLAINT WITH THE CABINET FOR HEALTH AND FAMILY SERVICES, OFFICE OF
HUMAN RESOURCE MANAGEMENT, EEO COMPLIANCE BRANCH, 275 EAST MAIN STREET, 5C-D, FRANKFORT,
KENTUCKY 40621 OR CALL (502) 564-7770 EXT. 4107.
IF YOU HAVE OTHER COMPLAINTS ABOUT YOUR CASE, YOU CAN CALL THE OMBUDSMAN’S OFFICE AT 1-800372-2973. TTY IS AVAILABLE AT 1-800-627-4702.
Signed _____________________________________
(Applicant or Recipient)
Date________________________
Cabinet for Health and Family Services
An Equal Opportunity Employer M/F/D
Page 1 of 2
Web site: http://chfs.ky.gov/
PART II. DECLINATION
[
]
I do not wish to register to vote at this time. I understand that if I decline to register to vote, my decision is kept
confidential and is used only for voter registration purposes.
Signed ________________________________________
(Applicant or Recipient)
Date________________________
Signed ________________________________________
(Worker)
Date________________________
PART III.
I have provided the applicant or recipient with a copy of this explanation.
Signed _____________________________________
(Worker)
Date________________________
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FS-8
(R. 10/08)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family
Department for Community Based Services
Division of Family Support
FOOD STAMP
SIMPLIFIED REPORTING REQUIREMENTS
HANDOUT
These are reporting rules for your household. The only changes you must tell your
worker about are:
WHEN YOUR HOUSEHOLD’S MONTHLY GROSS INCOME IS MORE THAN THE
AMOUNT LISTED ON THE CHART BELOW FOR YOUR HOUSEHOLD SIZE; OR
WHEN A MEMBER OF YOUR HOUSEHOLD WHO IS 18 YEARS THROUGH 49
YEARS OLD, AND SUBJECT TO ABAWD REQUIREMENTS, BEGINS TO WORK
LESS THAN 20 HOURS A WEEK.
Household
1
2
3
4
5
6
Size
Income
Limit
$1,127 $1,517 $1,907 $2,297 $2,687 $3,077
7
8
Each
Additional
Member
$3,467
$3,857
+390
Used for
Simplified
Reporting
Requirements,
Rights &
Responsibilities
with all Food
Benefit
Applications.
If your total gross income in a month’s time is more than the amount listed on the
chart for your household size, it must be reported to your worker at the food stamp
office.
Add all gross earned and unearned income received by your household in a month’s
time. Match it up with the amount on the chart. If your household’s gross income is
more than the amount listed for your last reported household size, you must report
the change within 10 days of the end of the month in which the change occurred.
If any working household members, who are age 18 through 49, and subject to
ABAWD requirements, have their hours reduced to less than 20 hours per week, you
must report to your worker within 10 days.
Note: Gross income means the amount of all earned and unearned income
before any deductions, such as taxes, are taken out.
Other changes may affect your food stamps. You may tell us about these changes
that could cause your food stamps to go up or down:
 Your household’s income goes up or down.
 You move and your rent and/or utilities change.
 When someone moves in or out of your household.
Cabinet for Health and Family Services
An Equal Opportunity Employer M/F/D
Back to 202
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Other Case Forms Include:
PAFS 126
KIM 77
Back to Start
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
PAFS-126
(R. 2/06)
Page 1 of 2
Change Report
Form
CHANGE REPORT FORM
Date _______________________
(Person Accepting Report)
_____________________________________
(Name of Person Reporting Change)
Used to record
reported
changes from
recipients
(Change Reported: [ ]In Person [ ]Phone
_____________________________________
Type of Case
[ ]St. Sup. [ ]MA [ ]FS [ ]K-TAP
(Phone Number of Person Reporting Change)
_____________________________________
(Case Name)
_____________________________________
(Case Number/SSN, if known)
Change Referred for Processing to: ___________________________________
(Worker Name)
(Date Referred)
ENTER CHANGE REPORTED IN EACH APPROPRIATE SECTION.
I.
ADDRESS CHANGE [ ]Residence Only [ ]Mailing Only [ ]Both
New Address:
Street
City
Apt.#
Zip Code
Phone
If mailing address is different from residence, did it change? [ ]Yes [ ]No
If yes,
Street
Apt.#
City
State
Zip Code
Do the same people live at the new address? [ ]Yes [ ]No
If no, also complete section II.
Expense
Amount
Frequency
Expense
Amount
Frequency
Rent
Mortgage
Taxes
Insurance
Are utilities included in the rent/mortgage? [ ]Yes [ ]No
If yes, is the household billed for excess utilities? [ ]Yes (list below) [ ]No
Is household billed for heating/cooling expenses? [ ]No [ ]Yes
Is household billed for utilities other than heating/cooling expenses: [ ]No [ ]Yes If yes, what are
they? _____________________________________________________________________________
Does household receive HEAP? [ ]No [ ]Yes
HH eligible for [ ]SUA [ ]BUA [ ]Homeless [ ]Actual
Does anyone help with payment of expenses? [ ]No [ ]Yes, who?
Does the household receive HUD assistance? [ ]No [ ]Yes, how much?
II.
CHANGE IN HOUSEHOLD COMPOSITION
Member
In/Out
Date
SSN
DOB
Sex
Race
Relation
If both parents are in home, is either unemployed or incapacitated? [ ]Yes [ ]No
Does this person have resources? [ ]Yes [ ]No. If yes, list type and amount.
Does this person have income? [ ]Yes [ ]No. If yes, complete section III.
Med.
Exp.
Eats
W/HH
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other Case
Forms
KIM-77 KIM-77
(R. 8/08) (R. 8/08)
921 KAR 3:030
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
Division of Family Support
Intent to
Apply
Intent to Apply
We want to be able to help you as soon as possible, so please answer the following questions.
Do you have a physical or mental condition that requires you to have special accommodations
during your application interview, such as needing a sign language interpreter? [ ] Yes [ ] No
If Yes, what do you need? ________________________________________________________
We can get a free interpreter for your interview if you have trouble speaking English.
Do you need an interpreter during your interview? [ ] Yes [ ] No
If yes, what language? ___________________________________________________________
Used for
applicants
with intent
to apply for
benefits
Important information for all applicants

Anyone who wants to receive K-TAP (cash assistance), Food Stamp or Medicaid benefits must
give us his or her social security number (SSN) and tell us about his or her citizenship or immigration
status. If you do not have a SSN we can help you get one if you are eligible for one. This will not delay
your application. Applying for a SSN is voluntary.

SSNs will not be used to report anyone to the Immigration and Naturalization Service (INS).

You do not have to tell us about the SSN, citizenship or immigration status of yourself or anyone else in
your home who does not want to receive benefits. Other members of your household can still get
benefits if they qualify.

SSNs are used to verify your family’s income and to do computer matches with other agencies such as
the Kentucky Department of Employment Services, the Internal Revenue Service and other matching
sources.

Anyone applying only for emergency Medicaid does not have to give us his or her SSN or tell us about
his or her citizenship or immigration status.

Receiving Medicaid, Kentucky Children’s Health Insurance Program (KCHIP), or Food Stamp benefits
will not affect your or your family’s ability to change your immigration status. An exception to this
is the use of long-term institutional care, such as a nursing home.

Receiving K-TAP or Supplemental Security Insurance (SSI) could cause problems for immigrants who
are trying to change their immigration status, especially if the benefits are your family’s only income.
If this applies to you, talk to an agency that helps immigrants with legal problems before you apply.

Refugees and persons granted asylum may receive any benefit, including K-TAP, without hurting their
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other Case
Forms
Clients receive these forms from the
PAFS 203 Checklist :
PAFS 120
FS 360
FS 500.1
FSET 101
PAFS 600
Civil Rights Pamphlet
Back to Start
Civil Rights
Pamphlet
Advises all
applicants of
their civil
rights,
including
their right
for a
hearing.
Back to
Checklist
Employment
and Training
Fact Sheet
Information
on the
Employment
Training
Program
Back to
Checklist
Able-Bodied
Adults
Without
Dependents
Fact Sheet
Back to
Checklist
Information
Needed to
Process a
Food Stamp
Application
Back to
Checklist
DCBS-1
(R. 10/05)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
INFORMED CONSENT AND RELEASE OF INFORMATION AND RECORDS
Name _________________________________________________________
SSN ______________________________
I understand to help my family and I get the services we need the Department for Community Based Services (DCBS) and other agency
staff persons may need to share information and records in order to provide or verify eligibility for these services. By signing this form, I give
DCBS staff or staff of another agency, authorized to act on behalf of DCBS, permission to get any information needed to see if I am eligible
for any assistance program. I also give permission for DCBS and the following agencies or persons listed below to share information and
records with one another about services, benefits or treatment provided to me and my family:
Name of Agency or Individual
Name of Agency or Individual
Name of Agency or Individual
My consent includes the following information and records (please put your initials beside each checked item that you consent to):
____ Medical and Physical Health Records (not HIV or AIDS)
____ Behavioral Health and Psychiatric Records (not Drug or Alcohol Abuse Patient Records or Psychotherapy Notes)
____ Psychosocial History
____ Housing Records
____ Psychological Test Results
____ Residential Records
____ Child Care Records
____ Child Support/ Spousal Support Records
____ Student School Records
____ Food Stamp Records
____ Long-term Facility and Alternate Care Records
____ K-TAP Records
____ Statement of Legal Status and Custody
____ Medicaid Records
____ Home Care and Home Health Records
____ Child Protective Services Records
____ Spouse Abuse and Rape Crisis Center Records
____ Adult Protective Services Records
____ Senior Program Provider Records
____ Financial Records
____ Homeless Shelter Records
____ Employment Records
____ Court Records
____ Other____________________________
This consent applies to the following members of my family for whom I have the legal authority to consent:
Member Name
SSN
-
Relationship
Member Name
-
SSN
-
Relationship
-
I understand that:

This authorization will be in effect for a period of __________________________ (not to exceed 12 months) from the signature date.

I may revoke this consent at any time in writing unless action has already been taken based on my consent.

DCBS will not condition treatment, payment, enrollment or eligibility for benefits on receipt of this form. Signing this form is voluntary, but
failing to sign it, or revoking it before the necessary information is obtained, could prevent an accurate or timely response and could
result in denial or loss of benefits.

Information may be disclosed with the other DCBS Divisions to assist in obtaining the requested services.

Information disclosed to DCBS may no longer be protected by the health information privacy provisions of 45 CFR Parts 160 and 164
pursuant to the Health Insurance Portability and Accountability Act (HIPAA).

Information may be redisclosed by DCBS without my consent if authorized by State Law or Federal Laws such as the Privacy Act or 42
CFR Part 2 or to comply with laws regarding mandatory reporting of suspected abuse, neglect or exploitation, or assessment that there
is a danger of serious harm to self or others.

I have received a copy of this form. I may also request a copy of the information retained with it.
Signature _________________________________________________________________
Date _____________
[ ] Client [ ] Parent [ ] Legal Guardian [ ] Other (specify) _____________________________________________________
Signature ________________________________________________________________
Date _____________
[ ] Client [ ] Parent [ ] Spouse [ ] Legal Guardian [ ] Other (specify) ___________________________________________
Witness Signature _________________________________________________________
Date _____________
Consent and
Release of
Client
Information
and Records.
Used when
additional
information
needs to be
obtained
from a third
party.
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PAFS-600
(1/09)
COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
DO YOU KNOW?
Do you have a physical or mental condition that makes it hard for you to:
Apply for K-TAP, Medicaid, Food Benefits or other benefits?
Keep appointments with us?
Do a task or activity we ask you to?
PAFS 600
Fact sheet for
Americans with
Disabilities Act
(ADA)
If you do, we can help you. We can also help you if you care for a family member
and that care makes it hard for you to get benefits. This flyer tells you why and
how we can help.
Americans with Disabilities Act (ADA)
The law: You have the right under the Americans with Disabilities Act (ADA) to
get
help applying for and keeping benefits. You can get help with any activity needed
to
use our programs.
Who it protects: You have rights under the ADA if any kind of health problem
makes it hard for you to do something basic and important, like:
•care for yourself
•walk, stand, or sit
•see, hear, or talk
•breathe
•learn
•remember things
•do tasks with your hands
•work
The problem can be physical, like diabetes, asthma, or migraine headaches. Or it
can be mental or emotional, like depression, anxiety, ADD or ADHD. It can also
be a learning disability.
You do not have to get disability benefits to get this help.
Back to
Checklist
Facts About
Food Stamp
Benefits
Information
Fact Sheet
Back to
Checklist
DCBS FORMS
Intranet; forms
for family
support
caseworkers.
Next
Screen
Family Support
Forms:
Access General
Forms
Workbook, or
scroll page to
access Table of
Contents for
Family Support
forms.
Comprehensive Table of Contents:
Section I Food Stamp Forms
Section II Public Assistance/Food Stamp
Forms
Section III Public Assistance Forms
Section IIIA KWP Forms
Section IV DCBS Forms
Section V Claims/Fraud Forms
Section VI Miscellaneous Forms
Section VII Publications
Section VIII KAMES Forms
Section IX Report Series Forms
Back to
Start
Don’t forget:
Some local offices use additional forms for
case setup. Check with your supervisor
regarding your office procedures.
You are now ready to continue with
assignments under Part I on Blackboard.
Back to
Start