Obsolete per IM-126 September 15, 2022
If applicable, discuss how the medical determination will be made. Include the responsibilities of both the claimant and FSD. Give the claimant all relevant medical forms and have the Medical Referral and Authorization Letter signed. Give copies of the following leaflets to each applicant: General Relief pamphlet, IM-4 General Relief Hearing pamphlet IM-4, Hearing Rights Medicaid and You pamphlet IM-4 Medicaid Complete the following forms, at a minimum: Application and Eligibility statement IM-1MA Third Party Resource Form, TPL-1 if necessary Referral to SSI if disability is expected to last 6 months or longer IM-76 Interim Assistance Reimbursement Agreement, IM-77 Identification Data, IM-35 Age Verification, IM-11 if needed Request for Information, IM-31A if needed Request for Direct Deposit, IM4DD if needed Explain the following eligibility requirements: residence, institutional residence, unemployability, SSI eligibility, Licensed Boarding Residential or Intermediate Home, Need, and resources. Prior month coverage.