P.O. Bx 99243 Referral Checklist Client Infrmatin: Please cmplete t the best f yur ability adding as many details as available. Budget: The budget shuld be filled ut as cmpletely as pssible. If yu are requesting utilities be paid by the representative payee service yu must have the utilities sent t the PO Bx address. This is dne by calling the utility cmpanies with the clients. Budgets may be revised as ften as pssible; hwever please ntify T.O.D., Inc. f any changes as sn as pssible. Spending Checks can be issued in ne f the fllwings ways: 1. Mnthly: 1 st (SSI) f 3 rd (SSD) f the mnth. 2. Bi-Mnthly: 1 st r 3 rd and again n the 15 th 3. Weekly: Checks wuld be mailed n Mndays. Client/Agency Respnsibility: Cntract describing the respnsibilities f the payee and client relatinship. Request Fr Additinal Funds: If there is remaining funds in the accunt please utilize this frm t request additinal funds. Advanced Ntificatin: Must have the client s signature. The riginal must be mailed t the PO Bx. Physician Statement: This is required when there was n previus payee. The riginals must be mailed t the PO Bx. Release: Please have this cmpleted and signed by the cnsumer. Recent Labs/Medicatins/Appintments: Please include the client s mst recent viral lad/cd4, mst recent appintment date, any future appintments, and medicatin list. Cpy f Pht ID: Please include a cpy f the client s pht ID. *Please send cmpleted applicatins t: Christina Farmartin C/O T.O.D., Inc. P.O. Bx 99243
P.O. Bx 99243 CLIENT INFORMATION Client Name Client Date f Birth Client Scial Security Number Client Address Client Telephne Client Race Client Age Recent VL Date Recent CD4 Date Last Appintment Scheduled Attended? Next Appintment Scheduled City and State f Client s Birth Maiden Name f Client s Mther Insurance SPBP enrlled (Y/N) Living Arrangement: Hmeless frm the Streets Hmeless frm Shelter Living w/ friends r relative Rental Husing Transitinal Husing Jail/Prisn Hspital Other: Referring Agency Name Agency Address Case Manager Name Case Manager Telephne# Case Manager Email
P.O. Bx 99243 CLIENT INFORMATION II Behaviral/Mental Health Illness: Please List Diagnses: Current r Past Drug Use: Please Explain: Current r Past Criminal Invlvement: Please Explain: D yu receive any ther incme? Please Explain:
P.O. Bx 99243 CLIENT INFORMATION III Please give a brief explanatin as t why the resurces f a representative payee are needed in this particular situatin (Please be as specific as pssible, this is needed fr prcessing by Scial Security) : D yu currently have a payee? If yes, please explain the reasn fr changing:
P.O. Bx 99243 BUDGET DATE INCOME RENT SSI: Due Date: SSD: DPW: Send T: Wages: Other: Ttal: Amunt: UTILITIES & EXPENSES *Please nte that all utilities requested t be paid by rep payee service must be sent t PO BOX address. This is dne by calling the individual utility cmpanies. Electric Gas Telephne Spending Check #1 Spending Check #2 Spending Check #3 Spending Check #4 Other Utility Yes r N Amunt Mnthly Spending Mney Disbursement Request ( ) Mnthly ( ) Bi-weekly ( ) Weekly Send T: *I request that The Open Dr, Inc. makes the afrementined payments n my behalf. I authrize this mnthly budget. (Client Signature) (Date)
P.O. Bx 99243 CLIENT/AGENCY RESPONSIBILITY Name SSN I hereby authrize The Open Dr, Inc. t manage my benefits and t serve as my rganizatinal representative payee. I understand that the Scial Security Administratin (SSA) r my emplyer will send my benefits t my rganizatinal representative payee. It is the duty f the representative payee t manage my benefits in my best interest with my prir knwledge and input. I hereby acknwledge that this cnsent is truly vluntary. It has been explained t me that the pint f cntact regarding payee budgeting, questins, and/r cncerns is the case manager listed in this applicatin. As a client f The Open Dr, Inc. Representative Payee Prgram, I have the right t cnfidential treatment f infrmatin prvided t any Agency staff member. The client s respnsibility is t prvide adequate, accurate infrmatin s that the agency will prvide efficient service t meet client needs. Date f Birth ( / / ) Beneficiary Signature SS# Date Beneficiary Address Phne #
P.O. Bx 99243 REQUEST FOR ADDITIONAL FUNDS Name SS# Amunt Requested: Reasn fr Request: Send T: Signature f Beneficiary Date * Please btain receipts fr additinal mney requested fr Scial Security reprting purpses.
SOCIAL SECURITY ADMINISTRATION TOE 250 Frm Apprved OMB N. 0960-0024 PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF PATIENT'S CAPABILITY TO MANAGE BENEFITS Paperwrk Reductin Act Statement - This infrmatin cllectin meets the requirements f 44 U. In replying, use this address: S.C. 3507, as amended by Sectin 2 f the Paperwrk Reductin Act f 1995. Yu d nt need t SOCIAL SECURITY ADMINISTRATION answer these questins unless we display a valid Office f Management and Budget cntrl number. We estimate that it will take abut 10 minutes t read the instructins, gather the facts, and answer the questins. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. Yu can find yur lcal Scial Security ffice thrugh SSA's website at www.scialsecurity.gv. Offices are als listed under U.S. Gvernment agencies in yur telephne directry r yu may call Scial Security at 1-800-772-1213 (TTY 1-800-325-0778). Send nly cmments relating t ur time estimate abve t: SSA, 6401 Security Blvd, Baltimre, MD 21235-6401. Privacy Act Statement Sectins 205(a) and 205(j), f the Scial Security Act, as amended, authrize us t cllect this infrmatin. The infrmatin is needed t make a determinatin regarding whether r nt the named individual shuld be paid benefits directly r whether benefits shuld be paid t a representative payee. The infrmatin yu furnish n this frm is vluntary. Hwever, failure t prvide all r part f the infrmatin culd prevent an accurate and timely decisin n the prper payee fr benefit receipt purpses. Frm SSA-787 (05-2010) ef (05-2010) Destry Prir Editins TELEPHONE NUMBER (Including Area Cde) ( ) - DATE SSA CONTACT IDENTIFYING INFORMATION (SSA Only) If different frm patient We rarely use the infrmatin yu supply fr any purpse ther than fr making a determinatin n a claim. Hwever, we may use it fr the administratin and integrity f Scial Security prgrams. We may als disclse infrmatin t anther persn r t anther agency in accrdance with apprved rutine uses, which include but are nt limited t: (1) t enable a third party r an agency t assist Scial Security in establishing rights t Scial Security NAME OF WAGE EARNER OR SELFbenefits and/r cverage; (2) t cmply with Federal laws requiring the release f infrmatin EMPLOYED PERSON frm Scial Security recrds (e.g., t the Gvernment Accuntability Office and Department f Veteran Affairs); (3) t make determinatins fr eligibility in similar health and incme maintenance prgrams at the Federal, state, and lcal level; and (4) t facilitate statistical research, audit r investigative activities necessary t assure the integrity f Scial Security prgrams. We may als use the infrmatin yu prvide in cmputer matching prgrams. Matching prgrams cmpare ur recrds with recrds kept by ther Federal, state r lcal gvernment agencies. Infrmatin frm these matching prgrams can be used t establish r verify a persn's eligibility fr Federally funded and administered benefit prgrams and fr repayment f payments r delinquent debts under these prgrams. SOCIAL SECURITY NUMBER A cmplete list f rutine uses fr this infrmatin is available in Systems f Recrd Ntices 60-0089 and 60-0222. The ntices, additinal infrmatin regarding this frm, and infrmatin regarding ur prgrams and systems, are available n-line at www.scialsecurity.gv r at yur lcal Scial Security ffice. PATIENT'S NAME PATIENT'S SOCIAL SECURITY NUMBER - - PATIENT'S DATE OF BIRTH - - PATIENT'S ADDRESS (Number and Street, City, State, and ZIP Cde) YOUR HELP IS NEEDED The patient shwn abve has filed fr r is receiving Scial Security r Supplemental Security Incme payments. We need yu t cmplete the back f this frm and return it t us in the enclsed envelpe t help us decide if we shuld pay this persn directly r if he r she needs a representative payee t handle the funds. Please Nte: This determinatin affects hw benefits are paid and has n bearing n disability determinatins; SSA will NOT pay fr this infrmatin. Thank yu fr yur help. WHO IS A REPRESENTATIVE PAYEE A representative payee is smene wh manages the patient's mney t make sure the patient's needs are met. The payee has a strng and cntinuing interest in the patient's well-being and is usually a family member r clse friend. WHO NEEDS A REPRESENTATIVE PAYEE Sme individuals age 18 and lder wh have mental r physical impairments are nt capable f handling their funds r directing thers hw t handle them t meet their basic needs, s we select a representative payee t receive their payments. Examples f impairments which may cause incapability are senility, severe brain damage r chrnic schizphrenia. Hwever, even thugh a persn may need sme assistance with such things as bill paying, etc., des nt necessarily mean he/she cannt make decisins cncerning basic needs and is incapable f managing his/her wn mney. PLEASE COMPLETE THE INFORMATION ON THE REVERSE OF THIS FORM
PATIENT'S NAME PATIENT'S ADDRESS (Number and Street, City, State, and ZIP Cde) PATIENT'S SOCIAL SECURITY NUMBER - - PATIENT'S DATE OF BIRTH 1. Date yu last examined the patient 2. D yu believe the patient is capable f managing r directing the management f benefits in his r her wn best interest? By capable we mean that the patient: Is able t understand and act n the rdinary affairs f life, such as prviding fr wn adequate fd, husing, clthing, etc., and Is able, in spite f physical impairments, t manage funds r direct thers hw t manage them. Yes If "Yes", please mit questin 3, but be sure t sign and date the frm. N If "N", please prvide a brief summary f the findings that led t this cnclusin. Als, cmplete questin 3. Unsure If "unsure", please explain. 3. D yu expect the patient t be able t manage funds in the future (fr example, the patient is temprarily uncnscius)? Yes N If yes, please explain. NAME OF PHYSICIAN/MEDICAL OFFICER (Please print.) TITLE ADDRESS (Number and street, City, State, and ZIP Cde) Frm SSA-787 (05-2010) ef (05-2010) TELEPHONE NUMBER (Include Area Cde) ( ) - I declare under penalty f perjury that I have examined all the infrmatin n this frm, and n any accmpanying statements r frms, and it is true and crrect t the best f my knwledge. I understand that anyne wh knwingly gives a false r misleading statement abut a material fact in this infrmatin, r causes smene else t d s, cmmits a crime and may be sent t prisn, r may face ther penalties, r bth. SIGNATURE OF PHYSICIAN/ DATE MEDICAL OFFICER