Maine Department of Health and Human Services Authorization for Release of Information

Transcription

1 Maine Department of Health and Human Services Authorization for Release of Information We are committed to the privacy of your health information. Please read this form carefully. Office of Maine Care Services Office for Family Independence Maine Centers for Disease Control and Prevention Dorothea Dix Psychiatric Center Riverview Psychiatric Center Individual s Name: Substance Abuse and Mental Health Services Office of Child and Family Services Office of Aging and Disability Services Other: Individual s Date of Birth: Individual s Social Security Number: Individual s Address: Street Town/City State Zip Code Records to be released, including written, electronic and verbal communication: All Healthcare, including treatment, services, supplies and medicines Billing, payment, income, banking, tax, asset, and/or other information regarding financial eligibility for DHHS program benefits such as MaineCare Limit to the following date(s) or type(s) of information: (e.g. lab test dated June 2, 2013 or hospital records from 1/1/12-1/15/12 ) I authorize the DHHS office(s) checked above to: Release my information to: Obtain my information from: Name: Address: Street Town/City State Zip Code Fax No., where applicable: Phone No. to verify Receipt of Fax If requesting that electronic information be transmitted by , please clearly print the address below: I understand that DHHS systems may not be able to send my information securely through . I understand that and the internet have risks that DHHS cannot control and that the information potentially could be read by a third party. I accept those risks and still request that DHHS send my information by . Initials Please allow the office(s) named above to disclose my information for the following purpose(s): Legal Insurance Coordination of Care Personal Request Other: DHHS Authorization Form 11/13 Page 1 of 2

2 By initialing below, I wish for my release to include the following types of records: Mental health treatment provider or program Substance/Alcohol/drug abuse treatment provider or program HIV infection status or test results: Maine law requires us to tell you that releasing this information may have implications. Positive implications may include giving you more complete care, and negative implications may include discrimination if the data is misused. DHHS will protect your HIV data, and all your records, as the law requires. I (individual/personal representative of individual named above,) give permission to the DHHS office(s) listed above to release and/or share my records as written on this form. This form will remain in effect for one year from the date below. Other releases of my information are permitted during that time unless I revoke this form. I further understand and agree that: DHHS will not condition my treatment, payment for services, or benefits on whether I sign this form, unless I need to sign this form so that the right offices of DHHS can decide if I qualify for benefits. I have the right to make a written request to access and copy my healthcare or billing information, and a copy fee will be charged as permitted by law. If I want a review of my mental health program or provider records before they are released, I can check here. I understand that the review will be supervised. I may take back my permission to share the records listed on this form at any time by contacting the Privacy Officer of the specific DHHS office at: I understand that taking back my permission does not apply to the information that was already shared with my signature on this form. If I revoke my permission, it may be the basis for denial of health benefits or other insurance coverage. I may refuse to disclose all or some health care information, but that refusal may result in improper diagnosis or treatment, denial of coverage or a claim for health benefits or other insurance, or other adverse consequences. DHHS offices will keep my information confidential as required by law. If I give my permission to share my records with people who are not required by law to keep them private, they may no longer be protected by confidentiality laws. If alcohol or drug provider or program records are included in this release, DHHS will tell the person receiving the records that they may not be shared with others who are not on this form without my written permission, unless required or permitted by law. I am signing this form voluntarily and I have a right to a signed copy of this form if I request one. Date: Signature Personal Representative s authority to sign: DHHS Authorization Form 11/13 Page 2 of 2

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13 Letter to Client Enclosing Copies of Pleadings and Notices JES 18 [Date] [Client Name] [Client Address] [Client Address Re: Special Needs Trust Dear Mr./Mrs./Ms. : The petition to the Probate Court to establish the Special Needs Trust has been filed with and accepted by the County Probate Court. Enclosed are copies of the complete Petition to Establish a Special Needs Trust with schedules A and B, as well as a copy of the draft Order to Establish the Special Needs Trust that we expect Judge to sign. Before Judge will sign the Order, we must provide notice of this proceeding to the Department of Health and Human Services and to the Social Security Administration. Those notices have been mailed and both have 21 days to respond to the notice of proceeding. Therefore, Judge will likely not review the petition until sometime after. I will be in touch with you as soon as we hear anything from the Court. Once Judge signs the Order, we will meet to sign the trust agreement. We will also review the draft Letter to Trustee and Letter to Trust Professional together to discuss your questions before final versions of these Letters are prepared. I welcome your questions and comments. Sincerely, Legal Assistant Enclosures 77

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15 Letter to Forward Joinder/Sponsor Agreement to Pooled Trust JES 19 [DATE] Mail correspondence regarding Maine Pooled Disability Trust to: Ms. Joan C. Cook Maine Pooled Disability Trust P.O. Box 495 Kennebunkport, Maine Mail correspondence regarding Maine Trust for People with Disabilities to: James Houle, Esq. The Maine Trust for People with Disabilities P.O. Box 9729 Portland, ME Re: [CLIENT] Dear [Joan/Jim]: Enclosed is a completed Sponsor Agreement for the consideration of the Board of the Maine Pooled Disability Trust (MPDT). This firm represents [through in his/her capacity as.] OR Enclosed is a completed Joinder Agreement for the consideration of the Board of the Maine Trust for People with Disabilities (MTPD). This firm represents [through in his/her capacity as.] Please let me know when the Board has had an opportunity to consider and act on the enclosed Sponsor Agreement. If the Sponsor Agreement is accepted and a sub-account is established at the MPDT/MTPD, please confirm that you will communicate with all the agencies currently providing benefits to to advise that a sub-account at the MPDT/MTPD has been established. Thank you for your consideration. Very truly yours, Jane Skelton jskelton@maineelderlaw.com JES/ Enclosure cc: [CLIENT] 79

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17 45-Day Letter JES 20 [Date] [Client Name] [Client Address] [Client Address Re: Special Needs Trust Dear Mr./Mrs./Ms. : On, 20, we mailed you draft documents for your review. These draft documents have no legal effect. Please let us know how we can help you get these in final form to be signed by you. As a reminder, I am being assisted by in this matter, and the direct phone number to s desk is If it would be helpful, will schedule a follow-up conference with me to take place by phone or in person. If we have not heard from you within the next six weeks, we shall assume that you do not want to proceed at this time, and I will arrange to close this firm s file. We can re-open the file in the future, but I would then need to charge for my time in reviewing the file again at my then-current hourly rate. I hope we hear from you soon. Best regards/very truly yours, Attorney Attorney/Assistant Enclosure 81

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19 90-Day Letter JES 21 [Date] [Client Name] [Client Address] [Client Address Re: Special Needs Trust Dear Mr./Mrs./Ms. : On, 20, we mailed you draft documents for your review. As we have not heard from you since then, we assume you need further assistance at this time. I will arrange to close our firm s file. If you decide you would like our advice and assistance in the future, do not hesitate to contact us. [IF THERE IS AN OUTSTANDING INVOICE, MENTION HERE. You have our invoice for legal services provided to date. Although we are closing our file, fees and expenses are payable. If you have questions or want to set up a payment plan, please contact in our Accounting Department. Her number is.] This confirms that we have returned all original documents and papers you gave us in connection with this matter. Consistent with our firm s standard practice, we will maintain a digital file in this matter for eight years. Best wishes to you,. Best regards/very truly yours, Attorney Attorney/Assistant Enclosure 83

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21 Document Execution Checklist JES - 22 ESTATE PLANNING DOCUMENT EXECUTION CHECKLIST Client Name(s) Client/Matter # Location of signing: Date: Responsible Attorney: 1. Order prebill for review by responsible attorney before meeting. Is there an unpaid balance?. Does responsible attorney want to deliver final invoice at the signing meeting? Other billing comments: 2. Review and assemble documents to be signed: Revocable Living Trust Agreement Certification of Trust Will Financial Power of Attorney Advance Health Care Directive Beneficiary Designation Forms Personal Property Memorandum Directive for remains/funeral instructions Other: 3. List everyone present in the room Testator(s) Lawyer: Also serving as a witness Notary: Two Disinterested Witnesses Anyone else: Name: Relationship to Testator: Name: Relationship to Testator: Comments: 85

22 Notary and witnesses must be continuously present in the room during the entire execution ceremony and be able to see the testator signing the documents. Other family members should usually not be present. Lawyer should usually not serve as the notary. 4. Before Signing Will 86 Introduce all participants. Evaluate capacity of testator and determine whether: 1. Intact No or very minimal evidence of diminished capacity; 2. Mild problems Some evidence of diminished capacity; 3. More than mild problems Substantial evidence of diminished capacity; or 4. Severe problems Client lacks capacity to proceed with representation and transaction. If more than mild problems, complete four page Capacity Worksheet for Lawyers from ABA s Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyer. R Review all documents with client Testator and witnesses sign revocable trust, if applicable 5. Procedure for signing Will: Ask the Testator to confirm: You are [testator name], you intend this document to be your Last Will and Testament, you want to sign it, you want the two of us (identify the witnesses) to witness your signature to your Will, and you are signing willingly. Testator responds in the affirmative. Ask the Testator to initial at the bottom of each page (including the final page if it follows the signature page) and sign above the typed name at the end. Testator initials and signs. Check to be sure all pages are initialed. The lawyer or notary asks the testator: Do you declare [to the notary] that you have signed this as your Last Will and Testament, willingly, as your free and voluntary act, that you are 18 years of age or older, of sound mind and under no constraint or undue influence? Testator responds in the affirmative. The lawyer or notary asks the witnesses: Do you each declare that you have witnessed [the testator] signing this instrument as his/her Last Will, that he/she signed it willingly, and that to the best of your knowledge [the testator] is 18 years of age or older, of sound mind, and under no constraint or undue influence? Witnesses respond in the affirmative. Witnesses sign. Notary signs and affixes seal. 6. Client and witnesses sign other documents: General Durable Financial Power of Attorney Advance Health Care Directive Beneficiary Designation Forms Personal Property Memorandum Other:

23 7. Determine clients wishes regarding storage of the original documents and delivery of copies (and confirm in closing letter). Ask client if they would like us to store the original will. (We prefer to deliver other original documents to the client for safe keeping, but will store powers of attorney and trust documents if requested). Ask clients if they would like to receive electronic (.PDF) copies of documents instead of or in addition to paper copies. Original documents to be retained by RW: None Will Financial Power of Attorney Advance Health Care Directive Other: Original documents delivered to clients at signing: None Financial Power of Attorney Advance Health Care Directive Specify: Original documents to be mailed to client with closing letter: None Specify: Copies to be mailed to clients with closing letter: None Specify (how many copies of each).pdf copies to be ed to clients: None All: ( address): Copies or.pdfs to be sent to others (family members, physicians, financial advisors, etc.) None Specify which documents and address: 87

24 8. Determine disposition of prior original documents. N/A no prior documents Client physically destroyed prior will in my presence. RW is retaining prior original will (e.g., capacity is in doubt and testator prefers prior will to intestacy) Comments: Advised clients to destroy prior original wills (confirm in closing letter) Comments: Client destroyed other original documents (specify): 9. Additional Comments/Issues for Follow Up /Matters to confirm in closing letter: 10. Following the signing meeting: o o o Responsible assistant saves this completed checklist as the memorandum of the signing meeting. Responsible assistant drafts closing letter for review by responsible attorney Responsible attorney reviews and signs closing letter. Send letter to trustee/tax professional, if applicable. Send final bill if applicable. Inventory and Storage of Documents: Document information is entered in data base spread sheet maintained in Worldox (Forms/Estate Planning/Estate Planning Aids) R XLS Any original documents are stored in RW vault PDFs of documents are saved to client file on Worldox 88

25 Letter to Maine DHHS for Approval of d4a Trust JES-23 Date Mr. Reinhold Bansmer Senior MaineCare Program Manager 19 Union Street State House Station #11 Augusta, ME Re: Special Needs Trust Dear Ron: Enclosed is a copy of the executed Special Needs Trust which meets the requirements of 42 U.S.C. 1396p(d)(4)(A) and Part 16, Section 4.53(A)(6)(a), of the MaineCare Eligibility Manual. Also enclosed is a DHHS Authorization and Release signed by which authorizes you to communicate with this firm. Please confirm that when s assets are transferred to the Trustee of this trust, the transfer will not result in a transfer penalty. Please also confirm that assets held in the trust will not be countable to for the purpose of his continued eligibility for MaineCare nursing home benefits. The necessary provisions for a trust pursuant to 42 U.S.C. 1396p(d)(4)(A) and Part 16, Section 4.53(A)(6)(a), of the MaineCare Eligibility Manual are outlined below: a. Will the trust be established for a disabled individual under age 65? Yes, is an individual with disabilities. He receives MaineCare benefits. He also receives Social Security Disability Income and Medicare benefits. was born on, and he is years old. He resides at Rehab and Living Center. b. Will the trust be established with the assets of a disabled individual? The trust will be funded with assets to which is entitled. Those assets were held in a trust following the death of his father and for the benefit of his mother,. Mrs. has now died. Those trust assets are being distributed to and his siblings. c. Is the disabled individual the beneficiary of the trust? During his lifetime, is the sole beneficiary of the trust. See Section 1.04 of the trust agreement. d. Did the individual with disabilities who has capacity establish the trust, or was the trust established by a parent, grandparent, legal guardian or court? 89

26 The individual with disabilities has capacity and established the trust. e. Does the trust provide that any state will be reimbursed for medical assistance paid on his or her behalf upon the termination of the trust or the death of the beneficiary? See Articles Three and Four of the enclosed trust agreement. Any assets remaining in the Trust upon termination of the trust, whether at the time of s death or otherwise, after payment of any and all legal obligations of the Trust, shall be reported to and available for reimbursement to the State of Maine and any other states that have provided with medical assistance prior to distributions to friends and family. f. Does the trust meet the special needs trust exception to the extent that assets of the beneficiary were put in the trust prior to the beneficiary attaining age 65? Yes. See the previous answers. g. Is the trust irrevocable? The trust agreement states that the trust is irrevocable. See Section In addition, there are named residual beneficiaries who are specifically identifiable in Section Thank you for your kind attention to the enclosed documents and your consideration of the request for approval of the form of the Special Needs Trust. Very truly yours, Attorney Attorney/Assistant Enclosure cc: 90

27 Summary Index Sheet JES 24 LAST FIRST INITIAL (Name of Testator) Testator s Address: DATE EXECUTED: LOCATION OF ORIGINAL WILL: FILE # PERSONAL REPRESENTATIVE(s) AND ADDRESS(es): RESPONSIBLE ATTY: WILL dated: Original located at: Simple Complex Disclaimer Marital Family/Credit Shelter SNT Pourover POA dated: Original located at: AGENTS: AHCD dated: Original located at: AGENTS: TRUST dated: Original located at: Type: Revocable Irrevocable Insurance Real Estate MAPT VAPT 1 st Party SNT 3 rd Party SNT Conduit/Stand Alone Retirement Charitable Other OTHER: 91

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