Free Form 02AS003E (ADS-RA-1) - Oklahoma

*02AS003E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Adult Day Services Referral/Application A. Participant information:
Name Race Mailing address Finding address Marital status Date of birth Case number Social Security number County Phone

B. Authorized representative information:
Name Address Daytime phone

C. Income documentation:
Source 1. Wages or salary 2. Self-employment, non-farm 3. Self-employment, farm 4. Social Security 5. Dividends, interest 6. Pensions and annuities 7. Unemployment Compensation 8. Workers' Compensation 9. Alimony 10. Child support 11. Veterans' benefits 12. TANF, A, B, D, and SSI 13. Other TOTAL Monthly gross income Documentation

Issued 11-1-2006

02AS003E (ADS-RA-1)

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02AS003E (ADS-RA-1)

Adult Day Services Referral/Application

D. Income computation:
OKDHS use only: Family size: Financial status: · · Eligibility predetermined Monthly income determination + Total monthly income - Work related expense = Total adjusted income Co-payment Ineligible Worker signature Date

·

Eligible

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Issued 11-1-2006

Adult Day Services Referral/Application

02AS003E (ADS-RA-1)

Adult Day Services Program participant and authorized representative responsibilities
I agree to: · · · · notify OKDHS of any changes in the amount of my income (received from any source) and any change in the size of my family. I further agree to make this notification within ten days of the change in income or size of family; notify OKDHS if there is any change concerning the person to be contacted in case of emergencies; be responsible to promptly pay or make arrangements to pay the day services center any co-payment; and notify OKDHS of any change of address and/or phone number for myself or authorized representative.

I understand that my adult day services may be terminated if: · · · it is determined that I am a danger to myself or others; my family member or my authorized representative is verbally abusive or otherwise poses a threat to the safety and well-being of the staff or participants of the center or to official representatives of OKDHS; or I, my family member, or authorized representative fails to cooperate with the adult day services delivery care plan, including failure to pay any applicable co-payments for which I am responsible.

I agree to the participant responsibilities as shown on this page. I agree to provide the OKDHS county office all information necessary to verify any statements made in the application and hereby give permission to OKDHS to obtain such verification. I affirm under penalty of perjury that this application is complete and correct to the best of my knowledge and belief. I understand and agree that if any statement is false and results in my receiving benefits for which I am not eligible, I am subject to prosecution for fraud. I understand that if my application is not completed within 30 days, I have a right to request a fair hearing. Adult day services center Applicant/authorized representative signature Adult day services representative signature Phone Date Title

Issued 11-1-2006

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