Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services (Page 31 of 38) in pdf

RIGHTS AND RESPONSIBILITIES

DHS-2

Rev: 01-16

Of Applicants/Recipients of RI Works Program (RIW), Supplemental Nutrition Assistance Program (SNAP), Medicaid,

Medicare Premium Payment Program (MPP), Child Care Assistance, General Public Assistance (GPA), RI SSI State

Supplemental Payment Program (SSP), and Katie Beckett

RIGHTS

You have a RIGHT to request, and if found eligible, to receive Financial or Medicaid or Supplemental Nutrition Assistance Program

benefits based on policies and standards established under State laws.

You have a RIGHT to appeal and to receive a Hearing before a Hearing Officer of the Department if you are dissatisfied with any

Department decision, or if the Department delays in making a decision. If you request a Hearing, your appeal will be heard promptly.

You may be represented by a lawyer or any other person you select to appear on your behalf. If you are not satisfied with any

Department decision regarding your application, you have a right to request a hearing. You must request a hearing within ninety (90)

days from the date you receive a written notice for Supplemental Nutrition Assistance Program benefits, thirty (30) days from the date

you receive a written notice for RIW, Child Care, and Medicaid, and (10) days from the date you receive a written notice for GPA.

Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights

regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs

are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or

retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require

alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should

contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities

may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in

languages other than English. To file a program complaint of discrimination, complete the

USDA Program Discrimination Complaint

Form,

(AD-3027) found online at: , and at any USDA office, or write a letter addressed to

USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.

Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil

Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:

program.intake@usda.gov.

This institution is an equal opportunity provider.

In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Section 504 of the Rehabilitation Act of 1973, as

amended (29 U.S.C. 794), Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.), and Title IX of the Education Amendments of

1972 (20 U.S.C. 1681 et seq.), the Food and Nutrition Act of 2008, the Age Discrimination Act of 1975, the U.S. Department of Health and

Human Services implementing regulations (45 C.F.R. Parts 80 and 84) and the U.S. Department of Education implementing regulations (34

C.F.R. Parts 104 and 106), and the U.S. Department of Agriculture, Food and Nutrition Services (7 C.F.R. 272.6); the Department of Human

Services (DHS), does not discriminate on the basis of race, color, national origin, disability, religion, political beliefs, age, religion or gender

in acceptance for or provision of services, employment or treatment, in its education and other program activities. Under other provisions of

applicable law, DHS does not discriminate on the basis of sexual orientation, gender identity or expression. For further information about

these non-discrimination laws, regulations and complaint procedures for resolution of complaints of discrimination, contact DHS at 57 Howard

Avenue, Cranston, Rhode Island 02920, telephone number 462-2130 (for deaf/hearing impaired 462-6239 or 711). The Community

Relations Liaison Officer is the coordinator for implementation of Title VI, the Office of Rehabilitation Services (ORS) Administrator or

his/her designee is the coordinator for implementation of the Title IX, Section 504, and ADA. The Director of DHS or his/her designee has

the overall responsibility for civil rights compliance for all agency programs.

You have a RIGHT to confidentiality. The Department uses information about you and other members of your household only for

purposes directly related to the administration of the programs and in compliance of the Health Insurance Portability and

Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information.

DHS has my consent to use or disclose protected health information for the purposes of treatment, payment and health care operations in

accordance with DHS notice of privacy practices.

The Department does not release information about you or other members of your household without your consent except as provided in

Rhode Island General Laws 40-6-12 and 40-6-12.1, and regulations set forth in the DHS and SNAP Policy Manuals. Any person found

guilty of violating the provisions of Rhode Island General Laws 40-6-12 shall be deemed guilty of a misdemeanor. Violators are subject

to a maximum fine of two hundred dollars ($200), or imprisonment of up to six (6) months, or both.

You have a RIGHT to file a joint application for more than one program or file a separate application for SNAP benefits without applying

for other program benefits. All SNAP applications, regardless of whether they are joint applications or separate applications, must be

processed for SNAP purposes in accordance with SNAP procedural, timeliness, notice, and fair hearing requirements. No household shall

have its SNAP denied solely on the basis that its application to participate in another program has been denied or its benefits under another

program have been terminated without a separate determination by the Department that the household failed to satisfy a SNAP eligibility

requirement. Households that file a joint application for SNAP and another program and are denied benefits for the other program shall not

be required to resubmit the joint application or to file another application for SNAP, but shall have its SNAP eligibility dtermined based on

the joint application in accordance with the SNAP processing time frames from the date the joint application was accepted by the

Department.

Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 31

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