|
Name
|
Number
|
Description
|
|
Aging and Adult Services Comprehensive Assessment
|
14-327
|
Assessment, documenting disabilities.
|
|
Application for Disability Insurance Benefits
|
SSA-16-F6
|
Apply for Social Security Disability.
|
|
Application for Supplemental Security Income
|
SSA-8001-F5
|
Apply for SSI.
|
|
Authorization for Source to Release Information
|
SSA-827
|
SSA uses this form to obtain medical records. (If disabled child is age 12 or over, child must sign the 827).
|
|
Disability Assessment
|
DSHS 14-332
|
Guide for determining when to request GAX.
|
|
Five-day Hospice Notice
|
13-746
|
Documentation of terminal illness.
|
|
Interim Assistance Reimbursement Authorization
|
DSHS 18-235
|
Repayment agreement when state benefits are duplicated by federal benefits.
|
|
Internet Adult Disability and Work History Report
|
I3368PRO
|
Replaces the SSA 3368 and SSA 3369. Education, employment, and medical information for SSA.
|
|
Medical History and Disability Report-Child
|
SSA-3820-F6 or i3820
|
Recording disability information for a child.
|
|
Physician’s Certification for Medicaid
|
DSHS 14-333
|
Approval or denial of GAX.
|
|
Reconsideration Disability Report
|
SSA-3441-F6 or i3441
|
Information when filing a request for reconsideration or hearing .
|
|
Referral for SSI
|
DSHS 11-017
|
Cover letter for application packet.
|
|
Request for Approval from State Office for Expenditure
|
DSHS 17-118
|
Obtain authorization to pay more than the maximum for SSI records.
|
|
Request for Hearing by Administrative Law Judge
|
HA-501-U5
|
Request an appeal hearing when a reconsideration is filed.
|
|
Request for Reconsideration
|
SSA-561-U2
|
Request a reconsideration.
|
|
Statement of Health, Education, and, Employment
|
DSHS 14-050
|
Record education, employment and medical information.
|
|
SSI Facilitation Program Medicaid Decision Letter
|
DSHS 14-343
|
Notify client when GAX benefits are denied.
|
|
SSI Legal Representation
|
DSHS 09-792
|
Client notice.
|
|
SSI Rights and Responsibilities
|
DSHS 14-411
|
Information for client.
|
