209.37 Verification of Deprivation SR 06-12, 10/06 (FAM-A)

Verify any of the three causes which deprive a child of parental support or care. Use any document that reasonably proves the deprivation. Also verify the parent-child relationship.

The following special verification requirements must be met:

Deprivation due to death: An affidavit of death used as verification must consist of signed statements by two individuals who have direct knowledge of the death. Verify the death at initial application only.

Deprivation due to continued absence: The individual must complete Form 773, Certification of Continued Absence. Verify continued absence at initial application and at each redetermination of eligibility.

Deprivation due to incapacity: If the individual is currently eligible for or receiving SSI or SSA based upon disability, they must complete Form 177, Non-Medical Evaluation of Disability, and Form 940, Cover Memo for Medical Eligibility Information. If the applicant is not already on SSI or SSA, the individual must complete Form 177 and return Form 921, Determination of Incapacity Status. If the applicant is unable to return Form 921, the Office of Medicaid Business and Policy (OMBP) determines incapacity using one or both of the following forms obtained from the Family Services Specialist at the District Office: Form 915, Medical Evaluation Initial, or Form 920, Psychiatric Evaluation Initial.

At the initial application interview, verify incapacity with the following:

• if the individual is currently receiving SSI or SSA based upon disability assist the applicant in completing Forms 177 and 940. The applicant must sign the forms;

• if the individual is NOT currently receiving SSI or SSA use the following verification process:

- assist the applicant in completing Form 177. The applicant must sign the form.

- complete Form 177a, Interview Observations;

- provide the individual with Form 921 for completion by their physician or psychologist.

• if the applicant does not return a Form 921 that clearly defines a qualifying disability do the following:

- for physically incapacitated parents, issue the applicant Form 915;

- for mentally incapacitated parents, issue Form 920;

- send returned verification to OMBP.

• assist the applicant in completing Form 11, Authorization to Release Information, when it is necessary to obtain additional information;

• gather additional information requested by OMBP on Form 940. OMBP will remain responsible for gathering additional medical data directly from a physician or institution; and

• gather any additional material which may bear on a decision.

NOTE: OMBP must be notified of changes in an incapacitated parent’s medical or employment status.

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Failure to comply: Failure to comply with verification requests results in the denial of NHEP/FAP financial and medical assistance for the entire case.