Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 33
Download a blank fillable Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38DHS-2 Rev. 10-14
Page 29
RIW/SNAP EBT Card Replacement Provisions:
Cardholders who request four (4) or more replacement EBT cards within a twelve (12) month period may be referred to the Fraud Unit
for investigation of misuse or abuse of the EBT card. Documented violations may result in one or more of the following actions:
Disqualification from the program;
Recovery through recoupment/restitution; and/or
Referral for criminal prosecution
In all cases, the agency shall act to protect households containing homeless persons, elderly or disabled members, victims of crimes,
and other vulnerable persons who may lose electronic benefits transfer cards but are not committing fraud.
I. RI WORKS PROGRAM, MEDICAID, CHILD CARE ASSISTANCE AND GENERAL PUBLIC ASSISTANCE.
LIENS AND ASSIGNMENTS
I understand that pursuant to Rhode Island General Law, Sections 40-6-9, 40-6-10, or 40-8-15, without the necessity of signing any
document:
a.) Regarding Child Support and Establishment of Paternity
I have assigned any and all rights that I may have for and on behalf of myself, and for and on behalf of my child or children, to the
Department of Human Services (DHS), against any person failing to provide for support, maintenance, and medical care for myself
and my minor child or children for whom assistance is paid by the DHS. The DHS is authorized to perform the act of instituting suit to
establish paternity and/or to collect support for myself or my child or children who receive or received assistance from the DHS.
b.) Regarding Amounts Recoverable from a Third Party
I have assigned any and all rights to the DHS, for and on behalf of myself and any person for whom I may legally act, for amounts
recoverable from a third party equal to the amount of financial assistance and Medicaid provided as a result of accident, injury, or
illness.
c.) Regarding Amounts Recoverable from Workers’ Compensation
The Department of Human Services may place a lien upon any pending award, order, or settlement, which I may be entitled to under
the provisions of the Rhode Island Workers Compensation Act, Chapters 28-29 through 28-38 of the Rhode Island General Laws. The
purpose of the lien is to secure reimbursement to the Department for financial and Medicaid payments made to me or on my behalf for
the period of time for which my workers’ compensation award, order, or settlement is made.
d.) Regarding Lien on Deceased Recipient’s Estate for Medicaid Reimbursement
The DHS may place a lien upon the estate of a Medicaid recipient who was fifty-five (55) years of age or older at the time of death.
R.I.G.L. 40-8-15 provides that the total sum of Medicaid paid on behalf of a Medicaid recipient who was fifty-five (55) years of age or
older at the time of receipt of such assistance shall be a debt to the state and shall constitute a lien upon the estate of the recipient in
favor of the DHS. However, the lien shall not be effective and shall not apply to the estate of a recipient who is survived by a spouse,
or a child who is under the age of twenty-one (21) or a child who is blind or permanently and totally disabled as defined in Title XVI
(SSI) of the Social Security Act.
I understand that as a condition of receiving RIW benefits, all persons from whom I am requesting RIW, unless exempt by law, are
required to comply with the RIW Program requirements.
I understand that this application will serve as authorization to the Department of Human Services to obtain from Medical
providers information that is pertinent to me or any person included in this application for as long as the case remains open.
I understand and agree that the DHS office may contact other persons or organizations to obtain the necessary proof of my eligibility
and level of benefits.
II. AUTHORIZED REPRESENTATIVE
You have a RIGHT to name an authorized representative. An authorized representative is a person designated by the head of the
household or the spouse, or any other responsible member of the household, to act on behalf of the household in applying for program
benefits, or using the benefits. The authorized representative for benefits may or may not be the same individual designated as an
authorized representative for the application process or for meeting reporting requirements. The authorized representative designation
must be made in writing.
You can authorize someone outside your home 1) to get your SNAP benefits for you and/or 2) to use them to buy food for you. If you
would like to authorize such representative(s), write the person’s name below.
Last Name
First Name
Middle Initial
Telephone Number
Address
City
Zip
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal