Form Dma-5096 - Documentation Of Need Page 2

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3.
Does the applicant have old bills?
Yes
No
Applicant____________________________________Month_________________________Amount__________________________Where________________________________________
Applicant ___________________________________Month_________________________Amount__________________________Where_________________________________________
4.
Does the applicant have any current bills?
Yes
No
Applicant ____________________________________Month_________________________Amount__________________________Where_______________________________________
Applicant ____________________________________Month_________________________Amount__________________________Where_______________________________________
5.
Does the applicant have anticipated medical bills?
Yes
No
Applicant ____________________________________Month_________________________Amount__________________________Where_______________________________________
Applicant ____________________________________Month_________________________Amount__________________________Where_______________________________________
6.
Based on observation, knowledge of client, and case record information, does the client have a condition listed below requiring the agency to obtain the necessary information?
Yes
No
A.
Check the condition that applies:
Blind
Developmentally Disabled
Homebound
Otherwise clearly unable to obtain
Deaf
Unable to speak English
Hospitalized
Other_________________________________________________
Mentally ill
Unable to read or write
Institutionalized
_________________________________________________
B.
Does the representative accept responsibility for obtaining information?
Yes
No
Explain____________________________________________________
7.
Was the DMA-5097 completed?
Yes
No
__________________________________________________________________________________________
8.
Other agency records checked:
Date Checked
No Record
Work First
______________
________________
Medicaid
______________
________________
Food Stamps
______________
________________
Services
______________
________________
9.
Referral made?
Yes
If yes, state reason for referral below.
No
Referral to Medicaid
Work First
_________________________________________________________________________________
MAD: _______________________________________________________________ MAF: _______________________________________________________________________
MPW: _______________________________________________________________ FPW: _______________________________________________________________________
MIC: _______________________________________________________________ WFFA: _______________________________________________________________________
MAA/MQB __________________________________________________________ NCHC: ______________________________________________________________________
Worker’s Signature _______________________________________
Client’s Signature _____________________________________________ Date _________________

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