223.03 Required Verification SR 12-26, 08/12 (FAM-A)

The individual who signs Form 800 or Form 800HR on behalf of the child who is applying for Children with Severe Disabilities (CSD) medical assistance, must provide verification of FANF 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 CSD medical assistance, the *Disability Determination Unit (DDU) requires all of the following for the medical eligibility determination:

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

• DDU Form 940, Cover Memo for Medical Eligibility Information;

• DDU 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.

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