ࡱ> }| @ 1Mbjbj  )))8|l}NKh4*>r,r,r,r,M--|o.@BJJJJJJ$LROJE|2M-M-|2|2Jr,r,K444|2r,r,B4|2B44VM=@>r,} n) )2= >K0NK=xO2O>O>./4!0|0...JJD4JUVENILE GUARDIANSHIP MEDICAL SUBSIDY APPLICATIONState of MichiganDepartment of Human ServicesChild s Name (Last, First, Middle)Birthdate (mm/dd/yyyy) FORMTEXT       FORMTEXT      Has Child Been Approved for the Guardianship Assistance Program?Has the Guardianship Order Been Signed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoPrint Guardian Name(s) (Prospective or Appointed) Phone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      COMPLETE THIS SECTION IF THE GUARDIANSHIP HAS NOT YET BEEN ORDERED BY THE COURTSupervising Agency NameWorker Name FORMTEXT       FORMTEXT      Complete AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      PhoneEmail( FORMTEXT    )  FORMTEXT       FORMTEXT      INSTRUCTIONS: Complete the following request to apply for certification of Juvenile Guardianship Medical Subsidy.A child may be eligible for medical subsidy if: The child is eligible for a Juvenile Guardianship Assistance Payment. The child is under age 18 at the time of the certification of the medical subsidy condition(s) by the DHS Subsidy office. The medical subsidy is necessary because of an identified physical, mental or emotional condition of the child which existed, or the cause of which existed, before the guardianship order by the court. Required documentation: For children who have not yet entered juvenile guardianship: Current (dated within the last 12 months) signed medical and/or professional reports of diagnosed conditions must be submitted with this application. An approved medical subsidy requested before the child is placed in juvenile guardianship is effective the date of the guardianship order. For children who are already in a court ordered juvenile guardianship: If you have current (dated within the last year) signed medical and/or professional reports of diagnosed conditions, attach them to this application If you do not have current signed medical and/or professional reports of diagnosed conditions, you may submit this application without attaching the reports. You must submit the reports within 90 days of the application. If the reports are received within 90 days of the application and the conditions are approved, the coverage will be effective back to the date the DHS Subsidy Office received the application. If documentation is not received within 90 days, the request will be denied. Submit the completed application and professional reports to: DHS Subsidy Office, 235 S. Grand Ave., Suite 412, P.O. Box 30037, Lansing, MI 48909.A medical subsidy is being requested for the following physical, mental or emotional condition(s).NAME OF DIAGNOSED CONDITION1. 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Macro recorded 12/06/04 by FIA? eight B@ !B@N !f(9d5(d,-9 9999999qo@ tab2 Macrod0x Macro recorded 12/06/04 by FIAx nine B@a !B@( !B]9d5(dg(9 9999999qXoP tab2 Macro(g( Macro recorded 12/06/04 by FIA( ten B@( !B@] !-l9d5(dB]9 9999999qXoPH4Attribute VB_Name = "NewMacros" Sub tab1() '0 x4 recorded 12/06/04 b y FIAB  Selection.GoTo What:=wdBookmark, ~:="twow 5Find.ClearFormattingYWith ^(@.TextPReplacement0wardTruBe&Wrap wd2Ask JFalsMat`chCas W`holeWWPildcGsSoundsLikq1All0R"End AP Az5|2 |2?||hree|w ||w|||3_>||e`|four?>|z|`a|d|||?>||}|4?>?>?>">iv|ߺ-|1B?>ߺ.?>?>?>?>?>,>5?>||o~|six/>?||%u .| "q.ab|0Ѕv || _|=|| |6&ϚϚ ϚϚŚsevenoooo{ ooo1!ooo!oo=*oof7=o@OOEeightOOOOOO>=.O0=4\,= ?f==?3==8OOo OOEnin|aZ١d(\\PX\ ?? ?-|>?>>>p}9hat:=wdGoToBookmark, Name:="ten" Selection.Find.ClearFormattingFWith  P0.Text0 = "&Replacementaward6TrueLWrapwdAskFals 3MatchCaseWholeWo7WildcGs SoundsLik1All0R"End  Sub xME (SLSS<N0{00020906-0000-0000-C000-000000000046}H(%H0(8K<xAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2ID="{A2AC010A-3398-4E73-B834-6317997AD7FB}" Document=ThisDocument/&H00000000 Module=MyInfo Module=Module1 Module=NewMacros as  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\Program Files\Common Files\Microsoft Shared\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.2#0#C:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{011B0288-DD3E-49B5-A37E-2A97CC021D64}#2.0#0#C:\DOCUME~1\bushd2\LOCALS~1\Temp\VBE\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M &*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#C:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLL#Microsoft Office 8.0 Object Library  K<5ThisDocument054b3e2157ThisDocument55 MyInfo064b3e2157 MyInfou]'Module10y4bcad22f|Module1[0NewMacros714bcae403NewMacrosJPY(pP0yZgLt (tab8?(tab9@x }HPROJECTPROJECTwmtCompObjjName="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="ADAF63CDA379A779A779A779A7" DPB="5D5F939DF34CF44CF44C" GC="0D0FC36DC31CC41CC4E3" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C MyInfo=0, 0, 631, 447, Module1=154, 203, 785, 650, NewMacros=22, 29, 653, 476, Z ThisDocumentThisDocumentMyInfoMyInfoModule1Module1NewMacrosNewMacros @ hBwbjbj O^"O^"6r6r6r6r6rJrnr{||l}Jrh}dHHHHH.v$R9 -6rHH 6r6rHH96rH6rH6r6r\wtH} n) nrڇ O099JrJr6r6r6r6r96r JrJr$nrJrJrnr FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEhhhhhhhhhhiiiii(i*i8i:i,hYqUj+hYqUj*hYqUjx*hYqUjhYqUmHnHuj)hYqUj(hYqUj>(hYqUj'hYqUhYqjhYqUj'hYqU/hhhi:i^iiiii jHjjjjjjk(kPkxkkkkt@tVUTSRQPOkNMLKJIHGFEDCBA@jjj j"j6j8jFjHjJj^j`jbjfjhjjjljjjjjjjjjjjjjjjjjjjjjjjkkkkӲ~v~k~jUmHnHuj0U jUj>0hYqUjhYqUmHnHuj/hYqUj.hYqUjhYq5UmHnHuj.hYq5U hYq5jhYq5Uj-hYqUhYqjhYqUj,hYqU*kkkk$k&k(k*k>k@kNkPkRkfkhkvkxkzkkkkkkkkkkkkkkkklttt ttttt.t0t>t@tBtVtXtfthtj47hYqUj~6hYqUj5hYqUUj)5hYqUjU4hYqUjt3hYqUj2hYqUj1hYqUjhYqUmHnHujhYqUjd1hYqUhYq2XT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       @thttttu*uLupuuuu v,vPvxvvvvw@wBwjihgfedcba`_^]\[ZYXWhtjt~tttttttttttttttttuuuuu(u*u,u@uBuDuHuJuLuNubudufulunupuruuuuuuuuuuuuj<hYqUj<hYqUj[;hYqUjhYqUmHnHuj:hYqUj&:hYqUj9hYqUj9hYqUjd8hYqUj7hYqUhYqjhYqU3uuuuuuvvvv v v v"v$v(v*v,v.vBvDvFvLvNvPvRvfvhvvvxvzvvvvvvvvvvvvvvvvvvwwwwjBhYqUjAhYqUjAhYqUj@hYqUj@hYqUjf?hYqUj>hYqUjhYqUmHnHuj>hYqUhYqjhYqUj=hYqU3ww.w0w2wwBwjhYqUmHnHuj(ChYqUhYqjhYqU/ =!"#$%eUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)Address1D CaseNumber Uppercase/Enter the Case Number (Example: V1234567A,B,C)D ClientCity UppercaseEnter the Addressee's City. ClientStateD ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation. ClientZipD ClientZip UppercaseKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)D CoAddress UppercaseaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).D CoAreaCodeEnter the County's Area CodeDCoCity UppercaseEnter the County's City.D CoExtensiond8(OJQJ_HmH sH tH XOX CaseNumber1?d8(OJQJ_HmH sH tH XOX ClientCity1@d8(OJQJ_HmH sH tH ZOZ ClientState1Ad8(OJQJ_HmH sH tH ZO"Z ClientZip1BdtCJOJQJ_HmH sH tH VO2V CoAddress1Cd8(OJQJ_HmH sH tH XOBX CoAreaCode1 Dd`CJOJQJ_HmH sH tH PORP CoCity1Ed8(OJQJ_HmH sH tH ZObZ CoExtension1Fd8(OJQJ_HmH sH tH ^Or^ CoPhoneNumber1Gd8(OJQJ_HmH sH tH ROR CoState1Hd8(OJQJ_HmH sH tH ^O^ CoSuppaddress1Id8(OJQJ_HmH sH tH XOX CountyName1Jd8(OJQJ_HmH sH tH \O\ CountyNumber1 Kd`CJOJQJ_HmH sH tH ROR CoZip1LdtCJOJQJ_HmH sH tH NON Date11 Md`CJOJQJ_HmH sH tH TOT District2 Nd`CJOJQJ_HmH sH tH LOL FaxAC Od`CJOJQJ_HmH sH tH VOV FirstName1Pd8(OJQJ_HmH sH tH XOX FirstName21Qd8(OJQJ_HmH sH tH `O"` GranteeAddress1 Rd`CJOJQJ_HmH sH tH \O2\ GranteeCareof Sd`CJOJQJ_HmH sH tH XOBX GranteeCity Td`CJOJQJ_HmH sH tH `OR` GranteeClientID Ud`CJOJQJ_HmH sH tH dObd GranteeFirstName2 Vd`CJOJQJ_HmH sH tH bOrb GranteeLastName1Wd8(OJQJ_HmH sH tH ZOZ GranteeState Xd`CJOJQJ_HmH sH tH VOV GranteeZip Yd`CJOJQJ_HmH sH tH TOT LastName1Zd8(OJQJ_HmH sH tH VOV LastName21[d8(OJQJ_HmH sH tH ROR OtherID1\d8(OJQJ_HmH sH tH ROR Section2 ]d`CJOJQJ_HmH sH tH ^O^ SuperAreaCode1 ^d`CJOJQJ_HmH sH tH `O` SuperExtension1_d8(OJQJ_HmH sH tH dOd SuperPhoneNumber1`d8(OJQJ_HmH sH tH `O` SupervisorName1ad8(OJQJ_HmH sH tH LO"L Unit2 bd`CJOJQJ_HmH sH tH PO2P Worker2 cd`CJOJQJ_HmH sH tH `OB` WorkerAreaCode1 dd`CJOJQJ_HmH sH tH bORb WorkerExtension1ed8(OJQJ_HmH sH tH TObT WorkerFax fd`CJOJQJ_HmH sH tH XOrX WorkerName1gd8(OJQJ_HmH sH tH \O\ WorkerName2hd8(5OJQJ_HmH sH tH ZOZ WorkerPhone1id8(OJQJ_HmH sH tH ^O^ WorkerTitle1jd8(5OJQJ_HmH sH tH LOL Emailkd8(OJQJ_HmH sH tH @0 0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumber CoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictEmail/FaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherID Section! SuperAreaCode"SuperExtension#SuperPhoneNumber$SupervisorName%Unit&Worker'WorkerAreaCode(WorkerExtension) WorkerFax* WorkerName+ WorkerName2, WorkerPhone- WorkerTitle.0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstName1GranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerName2 WorkerPhone WorkerTitleUser Input 10pt(<Pdu$5I]n  4EYm(<Pdx FFGhjkhtuwBw  ),689=>?    N 0|8MA