ࡱ> 5@ +hbjbj22 `~XX2$P֧(l˶h$R666"66R60 #H.$|0һNH83 6|!a333M\J \ADOPTION ASSISTANCE AND MEDICAL SUBSIDY APPLICATIONMichigan Department of Human Services(See Information/Directions on Page 3) A.IDENTIFYING INFORMATIONChild s Name (Last, First, Middle)Birthdate FORMTEXT       FORMTEXT      SWSS Log NumberSocial Security NumberCase Number FORMTEXT       FORMTEXT       FORMTEXT      Agency NameAgency Address FORMTEXT       FORMTEXT      Adoption Worker  Printed NameCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Email AddressAdoption Worker SignatureDate FORMTEXT       FORMTEXT      Telephone Ext. FORMTEXT       FORMTEXT      B.DOCUMENTATION REQUIREMENTS(Check each applicable box to indicate required document is enclosed with application packet.)1.All applications must include the following documents when original DHS-1341 is submitted: FORMCHECKBOX Original DHS-4081 Adoption Assistance and Nonrecurring Adoption Expenses Intent Statement. FORMCHECKBOX Copy of the childs birth certificate. FORMCHECKBOX Most recent petition removing the child from the home. FORMCHECKBOX Initial court order for most recent removal. FORMCHECKBOX Initial Service Plan (ISP). FORMCHECKBOX DHS-352 Initial Determination of Appropriate Foster Care Funding Source and copies of documentation that was used in completion of the DHS-352. FORMCHECKBOX Criminal clearances. FORMCHECKBOX Current DHS-470, 470A or 1945 DOC Assessment (dated within last six months), including documentation of no DOC rate. Projected rates must include all approval signatures.2.All determination of Care (DOC) rates, including projected rates. Documents required: FORMCHECKBOX Current Updated Service Plan (USP). FORMCHECKBOX Professional documentation that supports the DOC determination.Above Level III DOC rates: FORMCHECKBOX Approval memo from appropriate manager (dated within last six months), including the supporting documentation. FORMCHECKBOX Description of childs special needs and specific information showing how the above level III DOC rate was calculated.3.Other Payment Resources Documents required if Yes box(es) checked in Section D: FORMCHECKBOX Completed DHS-4813 Adoption Support Subsidy Program Other Payment Resources form.4.Medical Eligibility - Section E (Includes both Adoption Medical Subsidy and Medicaid for non title IV-E funded.) subsidies.)Documents required: FORMCHECKBOX For medical subsidy: Signed professional documentation for each condition. FORMCHECKBOX For Medicaid: Documentation of conditions requiring medical, mental health or rehabilitative care.NOTE: The Adoption Subsidy Office may request documentation in addition to 1-4 above.C.ELIGIBILITY INFORMATIONAnswer All Yes/No Questions1.Have all parental rights been terminated?1. FORMCHECKBOX  Yes FORMCHECKBOX  No2.Is the child a member of an American Indian tribe?2. FORMCHECKBOX  Yes FORMCHECKBOX  No3.Is the child under Michigan court jurisdiction as a result of an abuse and/or neglect proceeding?3. FORMCHECKBOX  Yes FORMCHECKBOX  No4.Has the adoption been finalized by the court?4. FORMCHECKBOX  Yes FORMCHECKBOX  No5.Has the potential adoptive family signed Section 1 of the DHS-4081 Adoption Assistance/Nonrecurring Adoption Expenses Intent Statement, requesting adoption assistance?5. FORMCHECKBOX  Yes FORMCHECKBOX  No6a.Is the child SSI eligible? If yes, attach DHS-4813.6a. FORMCHECKBOX  Yes FORMCHECKBOX  Nob.Is the child age 3 years or more?b. FORMCHECKBOX  Yes FORMCHECKBOX  Noc.Does the child receive a foster care Determination of Care (DOC) rate Level 2 or higher? c. FORMCHECKBOX  Yes FORMCHECKBOX  Nod.Is the child being adopted by a relative? d. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, Family Name: FORMTEXT      Relationship: FORMTEXT      e.Is the child being adopted by the parent of his/her previously adopted sibling?e. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, Sibling s Adoptive Name: FORMTEXT      Birthdate: FORMTEXT      f.Is the child a member of a sibling group being adopted together with at least one sibling who has been approved for the Adoption Support Subsidy Program?f. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, All Sibling Name(s): FORMTEXT      Birthdate(s): FORMTEXT      7.Is the adoptive parent the birthparent of the child?7. FORMCHECKBOX  Yes FORMCHECKBOX  NoD.FUNDING DETERMINATION INFORMATION1.Is the child a child of a minor parent receiving title IV-E foster care payments? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, minor parents name: FORMTEXT      DOB: FORMTEXT      2.Was the child previously adopted? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Adoptive Name FORMTEXT      Did the child receive Adoption Subsidy in a previous adoption? FORMCHECKBOX Support FORMCHECKBOX Medical FORMCHECKBOX None FORMCHECKBOX Unknown3.Has the child ever been in foster care 60 consecutive months or more? FORMCHECKBOX Yes FORMCHECKBOX No4.Criminal HistoryList name/DOB of all adult members 18 years or older living in the prospective adoptive parental home:Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Name: FORMTEXT      DOB: FORMTEXT      Do any of the above adults have felony convictions for any of the following: FORMCHECKBOX  Yes FORMCHECKBOX  NoChild abuse or neglect, spousal abuse Crime against children, including pornographyViolence, rape, sexual assault, homicide Within the last five years: physical assault, battery, or a drug related offenseIf yes, name: FORMTEXT      DOB: FORMTEXT      Last Clearance Date: FORMTEXT       FORMTEXT      DOB: FORMTEXT      Last Clearance Date: FORMTEXT      E.OTHER PAYMENT RESOURCES INFORMATIONIs the child eligible for or receiving any of the following payment resources?1.Supplemental Security Income (SSI) FORMCHECKBOX  Yes FORMCHECKBOX  No2.Retirement, Survivors and Disability Insurance (RSDI) FORMCHECKBOX  Yes FORMCHECKBOX  No3.Veterans Administration Benefits (VA) FORMCHECKBOX  Yes FORMCHECKBOX  No4.Family Independence Program (FIP)$ FORMTEXT      /per month FORMCHECKBOX  Yes FORMCHECKBOX  No5.County Child Care Funds (CCF) FORMCHECKBOX  Yes FORMCHECKBOX  No6.Other: FORMTEXT       FORMCHECKBOX  Yes FORMCHECKBOX  NoF.MEDICAID AND MEDICAL SUBSIDY ELIGIBILITY INFORMATIONDoes the child have any of the following conditions?YesNo FORMCHECKBOX  FORMCHECKBOX Prenatal Drug/Alcohol Exposure (attach medical birth record). FORMCHECKBOX  FORMCHECKBOX Chronic Physical/Medical (List Conditions): FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Developmental (List Conditions): FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Mental Health (List Conditions): FORMTEXT      AUTHORITY: P.A. 280 of 1939 COMPLETION: Voluntary PENALTY: Program eligibility will not be determined.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. INFORMATION/DIRECTIONS GENERAL INFORMATION Adoption Worker completes this form when a family has been identified as an appropriate family to adopt the child and the family is requesting a determination of eligibility for Adoption Support Subsidy and associated Medicaid (MA) benefits, Nonrecurring Adoption Expenses (NRE) and Adoption Medical Subsidy. Each section of the application must be completed in its entirety and required supporting documents must be submitted with the application. All Yes/No questions must be answered. 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ZCJaJhuhCJaJhuhlx^CJaJh$jh$jCJ aJ h.CJaJh"Y-CJaJh*CJaJhuh1CJaJh1huh1CJ aJ *[9:i;XXXBYYYYYWZZZZyy0 & F d8$Ifgd0 hd8$Ifgd0 hdt$Ifgd0 & F &d8$If^gd0 h@d8$Ifgd0 hdt$IfgdnqE0 & F VVd8$If^V`gdComplete the DHS-1341M, Adoption Medical Subsidy Application when the prospective adoptive family is requesting Medical Subsidy only or when adding conditions after an initial application has been submitted. A. IDENTIFYING INFORMATION Complete all information regarding the child and the adoption agency in this section. Enter printed name, date, email address and telephone number. Sign the DHS-1341 as verification of all information provided in the application packet. B. DOCUMENTATION REQUIREMENTS Check each applicable box to verify required document is enclosed with the application packet. The Adoption Subsidy Office (ASO) may request additional documentation during the review process. C. ELIGIBILITY INFORMATION (#s 1-7) Answer all Yes/No questions and attach required supporting documents. Clarifications: Q1. Parental rights are terminated either through court action or voluntary release by parent(s). Q3. In most termination court orders, the order will have a N/A (Neglect/Abuse) included in the court file number. Q5. The family must sign the DHS-4081 in only one section. The ASO accepts only the original signed unaltered form. Q6a. A child receiving SSI benefits only (no foster care payment) may be eligible for adoption support subsidy. Q6b. The child must be age 3 by DHS-1341 form completion date. A copy the childs birth certificate must be submitted. Q6c. If the child receives a foster care Determination of Care (DOC) rate at any level, a copy of the DHS-470, 470A or 1945 DOC Assessment (dated within the last six months), the Updated Service Plan (USP), and all documents used to support the DOC rate must be submitted with the DHS-1341 application. If a child receives a level IV DOC rate, the following documentation in addition to the above must be submitted with the application: documentation identifying how the level IV rate was determined and a copy of the most recent request/approval by the Area Manager (dated within the last six months). Q6d. The definition of Relative can be found in policy CFG (Child and Family Glossary). Q6e. Adoption support subsidy eligibility is not required for the previously adopted sibling. Q6f. The plan must be for the sibling group to be adopted together at the same time. At least one sibling must qualify for the Adoption Support Subsidy Program as individual. Q7. A child being adopted by a birth parent is not eligible for adoption programs. D. FUNDING INFORMATION Q1. If the child is a child of a minor parent covered by title IV-E foster care payments, enter the minor parents name and date of birth. Q2. Answer the question and provide applicable information concerning the childs previous adoption. Q4. Answer the question and provide applicable information concerning criminal history of any member in the prospective adoptive parent(s) household. E. OTHER PAYMENT RESOURCES INFORMATION Answer all Yes/No questions. If Yes for any question, complete and attach the DHS-4813 Adoption Support Subsidy Program Other Payment Resources. F. MEDICAID AND MEDICAL SUBSIDY ELIGIBILITY INFORMATION Answer Yes/No question, check applicable boxes, list conditions, and submit current supporting professional documentation. Chronic conditions include those either conclusively diagnosed or an identified physical, mental or emotional health condition requiring professional monitoring or rehabilitative care. Current and signed professional documentation (dated within the last year) identifying the condition(s) and providing status and treatment of the condition(s) must be submitted with the application packet. Medical subsidy may also be requested by submitting the DHS-1341M. APPLICATION SUBMISSION Mail the completed application DHS-1341 and all required supporting documents to: Adoption Subsidy Office Eligibility Unit Michigan Department of Human Services, Suite 412 P.O. Box 30037 Lansing, MI 48909 DHS-1341 (Rev. 10-09)  PAGE 2 Distribution: Original Adoption Subsidy Program Office All previous editions obsolete. MS Word Make a copy for files DHS-1341 (Rev. 10-09)  PAGE 3 All previous editions obsolete. 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