Form Dss 5120a - Redetermination Of Foster Care Assistance Benefits And/or Medical Assistance - North Carolina Department Of Social Services Page 3

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PART III DOCUMENTATION
1. FOSTER CARE ELIGIBILITY:
IV-E
_______________
SFHF
_______________
TEA
_______________
All COUNTY _______________
Foster Care Eligibility Period: from ____________to ______________
2. MEDICAID INFORMATION: (For purpose of Medicaid card).
Certification Period for MA:
from___________________ to_____________________
Medicaid Category
__________________
Individual EIS ID: _____________________
Child’s Countable Income _____________________ Full Time Student?
Yes
No
Child’s Countable Resources ___________________
Foster Parent Name and Address:
________________________________________
________________________________________
Is this a Licensed Foster Home?
Yes
No
3. HEALTH INSURANCE
Does the child’s situation in reference to private health insurance remain the same as in the last
review? Y _________ N __________ How verified?
If “no”, discuss any additional private health insurance available to the child, including the name of the
insurance company, the address where the claims should be mailed, and the name and social
security number of the person who carries the insurance. Or discuss the loss of any health
insurance.
________________________________________________________________________________
________________________________________________________________________________
4. CHILD SUPPORT
Are any of the named parents paying court ordered child support? Yes ____________ No _____________
If Yes, indicate:
Amount______________
Frequency____________
By whom_____________
Do you want to pursue child support from any Parent?
Yes ___________ No____________
If Yes, who _____________________________________________________________________________
If No, why not___________________________________________________________________________
Sign and verify eligibility
______________________________________
__________________________________
__________
SOCIAL WORKER
SUPERVISOR
DATE
DSS 5120A Rev. (4/2010) Child Welfare Services Section
3

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