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Form Dhcs 7089 - California Screening Worksheet Disabled Widow-Er Checklist Ages 50 To 64 - Health And Human Services Agency

State of California—Health and Human Services Agency

Department of Health Care Services

SCREENING WORKSHEET

DISABLED WIDOW(ER) CHECKLIST (DW)

AGES 50 TO 64

PERSON’S NAME: ______________________________

Date SSI/SSP Last Received: _______________ Date Title II Payments Began: ____________

(Must be verified through an award letter to the client or through SSA Office)

Screening Process:

If the answers to all the questions below are yes, the individual is a potential DW.

1. Is this person currently receiving Title II widow’s insurance benefits?

_________

2. Has this person lost SSI/SSP because of the receipt of certain Title II

payments?

_________

3. Has this person received SSI/SSP in the month prior to the month in

which he/she began to receive Title II payments?

_________

4. Is this person eligible for SSI/SSP in the absence of all Title II

insurance benefits under Section 202 of the Social Security Act?

_________

Title II Section 202 benefits:

Old-age insurance benefits

Wife’s insurance benefits

Husband’s insurance benefits

Child’s insurance benefits

Widow’s insurance benefits

Widower’s insurance benefits

Mother’s and father’s insurance benefits

(Title II disability benefits are found under section 223)

5. Is this person not receiving Medicare Part A benefits?

_________

The client must be sent an approval or denial notice of action if the person passed the

screening test.

THIS PROGRAM IS AIDED UNDER AID CODE 36.

NOTE: On all approval notices, be sure to advise the client that they must report

immediately any approval they may receive for Medicare Part A benefits.

DHCS 7089 (05/07)

Form Dhcs 7089 - California Screening Worksheet Disabled Widow-Er Checklist Ages 50 To 64 - Health And Human Services Agency