SA Manual Appendix A Forms
Special Assistance Manual for Adults - Appendix A Forms
- DSS-1473 Request for State Appeal
- DSS-1656 Refund Receipt (Collection of Overpayment)
- DMA-2041 Third Party Health and Accident Resources Information
- DMA-2043 Third Party Liability Accident Information Report
- DSS-2216 Request for Record
- DSS-3431 Request for Financial Information
- DMA-5010 Referral for Inpatient Hospital and Intermediate Care Facilities
- DMA-5022 Retroactive Eligibility Checks/ID Cards
- DSS-8108 Notice of Benefits
- DSS-8109 “Your Application For Benefits Is Being Denied Or Withdrawn”
- DSS-8110 “Your Benefits Are Changing” (Timely/Adequate Notice)
- DSS-8113 Wage Verification
- DSS-8129 Request for Replacement Check and Affidavit
- DSS-8176 Contribution Report
- DSS-8189 Appointment Notice
- DSS-8194 Income Maintenance Transmittal Form
- DMA-372-124-ach-ia Adult Care Home FL2 Form
- DMA-5001 Notice on the Use of Social Security Numbers
- DMA-5049 Referral to Local Social Security Office
- DMA-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice
- DMA-5094 Notice of Your Right to Apply for Benefits
- DMA-5095 Medicaid/Work First Notice of Inquiry
- DMA-5097 Request for Information
- DMA-5155 Verification of Cash Value of Life Insurance
- DMA-5202C Designation of Authorized Representative - Appendix C
- DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964
- DSS-5023: Direct Deposit Enrollment Authorization Form
- DSS-6969: Consent for Release of Information
- DSS-8201: County Responsible Overpayment
- DSB-2202: DSB/Report of Eye Examination