Form Dss 5120a - Redetermination Of Foster Care Assistance Benefits And/or Medical Assistance - North Carolina Department Of Social Services
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3REDETERMINATION OF
FOSTER CARE ASSISTANCE BENEFITS AND/OR MEDICAL ASSISTANCE ONLY
__________________________ COUNTY DEPARTMENT OF SOCIAL SERVICES
PART I: CHILD INFORMATION
Child’s Name__________________________________ DOB______________ Case # _________________
Original Placement Authority
Type __________________ Date _________________________
This refers to how the child entered care for present removal (VPA, Relinquishment or Judicial Determination)
Original Funding Eligibility
Type __________________ Date _________________________
This refers to funding source for which child was originally eligible (indicate IV-E SFHF, TEA or All County)
.
Current Funding Source (if different)
Type __________________ Date _________________________
Why did the funding source change?
____________________________________________________
This refers to the funding source from which payments are being made at this redetermination date.
This form must be completed at least every 12 months or at any time when the agency receives
information that would affect any questions listed below. This form is completed for both funding
source and to document Medicaid eligibility. Children who came into care on a relinquishment are
eligible for SFHF (or all county funds) only. This should be reflected in the redetermination.
Note: If child was not initially IV-E eligible, he/she will never be for this removal period. If the child is initially IV-
E eligible and subsequently looses that eligibility, the child may regain eligibility when all requirements are met.
PART II
LEGAL RESPONSIBILITY
.
Complete Appropriate Section Below
A. CARS Agreement
th
1. Has the child reached his 18
birthday?
Yes
No
If Yes, continue to question 2.
If no, proceed to questions about appropriate removal method (B, C or D) below.
2. Has child signed a VPA/CARS to remain in foster care?
Yes
No
Give date signed
3. Is child in school or approved training program?
Yes
No How verified _____ ____________
If answer to either question 2 or 3 is No, child not eligible for any foster care funds.
If answer to questions 1, 2 and 3 is Yes, child is eligible for SFHF. Go to Part III and mark SFHF.
B. VPA Removal
(complete for any removal by a VPA)
If the child has been in care 180 days, has there been a judicial determination within that 180 days that
continuing in placement is in the child’s best interests? This finding may be made in any order of the Juvenile
Yes
No
______________
Court.
Give date judicial determination issued
If yes, proceed to Part III.
st
If no, child is ineligible on the 181
day and will remain so for this episode of care. Proceed to Part III and
mark All County.
Note: Eligibility is based on how the child came in to care, so it is irrelevant if the agency later files a petition
and obtains custody of the child.
1
DSS 5120A Rev. (4/2010) Child Welfare Services Section
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