223.03 Required Verification SR 05-25, 08/05 (FAM-A)

The individual who signs Form 800 or Form 800HR on behalf of the child, must provide verification of TANF medical assistance eligibility criteria except for living with a specified relative and deprivation of parental care and support.

If a preliminary determination of eligibility, including a manual computation of financial eligibility, indicates the child would be eligible for medical assistance, the *Office of Medicaid, Business, and Policy (OMBP) requires all of the following for the medical eligibility determination:

• *a separate Form 900, Authorization for Release of Protected Health Information, for each provider listed on the Form 968;

• Form 940, Cover Memo for Medical Eligibility Information;

*

• Form 968, Children with Severe Disabilities Report of Parent of Guardian; and

• * a copy of the child’s Individual Education Plan (IEP) or "504" Plan, if available.

*OMBP is responsible for requesting additional information or verification, if required, to complete the medical eligibility determination.