Form Aap 3 - Reassessment Information - Adoption Assistance Program Page 2
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3State of California – Health and Human Services Agency
California Department of Social Services
Check (p) one of the following:
1. I/We no longer wish to receive an AAP benefit and/or Medi-Cal coverage for the child. I/We request
to sign a deferred AAP agreement to retain our child’s AAP eligibility status for access to benefits at an
unspecified future date.
2. I/We continue to need an AAP benefit and/or Medi-Cal coverage for our child. The care and
supervision needs of the child and family circumstances have not changed.
3. I/We continue to need an AAP benefit and/or Medi-Cal coverage for our child. I am/we are requesting
an increase in the AAP benefit due to a change in the child’s care and supervision needs and family
circumstances. I am/we are providing the agency documentation to support my/our request to
renegotiate our child’s AAP benefit. (Please complete Section I.)
4. I/We continue to need an AAP benefit and/or Medi-Cal coverage for our child. I/We request that
the AAP benefit for the child be decreased to $ _______________ due to a change in the child’s care
and supervision needs and family circumstances. I/We understand if at anytime our child’s needs
change we may contact the agency to renegotiate the AAP benefit.
SECTION I
1. I am/We are requesting an increased AAP benefit based on the following care and supervision needs of
our child and circumstances of the family:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I have attached written documentation to support my/our request for a benefit increase.
2. HEALTH INSURANCE
Does the family have health insurance?
YES
NO
If yes, name of insurance plan: __________________________________________________________.
Is the child currently covered by this insurance?
YES
NO
If no, reason: _________________________________________________________________________.
3. OTHER INFORMATION
a. Is the child a Regional Center client?
YES
NO
If yes, which Regional Center: _________________________________________________________.
AAP 3 (12/17)
Page 2 of 3
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