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

The individual who signs Form 800 or Form 800HR to apply for Home Care for Children with Severe Disabilities (HC-CSD) on behalf of the child must provide verification of FANF 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 the child would be eligible for HC-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 or 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 HC-CSD medical eligibility determination.