225.03 Required Verification SR 04-04, 05/04 (FAM-A)

The individual who signs Form 800 or Form 800HR to apply on behalf of the child must provide verification of TANF medical assistance eligibility criteria except for deprivation of parental care and support.

• Require written verification of the child’s age.

If a preliminary determination of eligibility, including a manual computation of financial eligibility, indicates that the child would be eligible for medical assistance, require the individual to provide the information needed by the Office of Health Planning & Medicaid (OHPM) to determine medical eligibility.

• Require all of the following forms:

- Form 11, Authorization to Release Information;

- Form 940, Cover Memo for Medical Eligibility Information;

- Form 967, Children with Severe Disabilities Report of Medical Findings;

- Form 968, Children with Severe Disabilities Report of Parent or Guardian;

- Form 969, Children with Severe Disabilities Report of Medical Care; and

- Form 970, Children with Severe Disabilities Authorization to Release Information.

• If the child is mentally disabled, also require the following:

- Forms 966a and 966b, Children with Severe Disabilities Report of Mental Status.

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