Form DHS-4334 "Icpc Financial/Medical Plan" - Michigan

What Is Form DHS-4334?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2005;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-4334 by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-4334 "Icpc Financial/Medical Plan" - Michigan

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ICPC FINANCIAL/MEDICAL PLAN
Michigan Department of Human Services
Child’s Name:
DHS Case Number #
DOB:
Check one:
male
female
FINANCIAL PLAN (check one)
Person or Facility child is to be placed with is financially able and willing to support this child.
Michigan will provide a foster board payment once the placement resource is licensed as a foster home.
Planning to apply for assistance for the child in the receiving state.
This is a return to a parent. Parent is financially responsible for the child.
Eligible to receive adoption subsidy payments from Michigan for the child.
Residential/Institutional Payment
Other – Specify:
MEDICAL PLAN (check one)
Child is IV-E eligible. The receiving state will arrange for Medicaid coverage based on the provisions of the
COBRA legislation (Title IV-E). Attached IV-E verification (DHS-352).
Child is not IV-E Eligible. The sending agency will provide a medical card and/or reimbursement for the child’s
medical expenditures incurred with prior approval. Include billing and medical emergency instructions.
Person or Facility child is to be placed with agreed to provide financially for the medical needs of the child.
This is a return to parent. Parent will provide medical for the child.
Other – Specify:
The Michigan sending agency remains ultimately financially responsible for the child and will retain jurisdiction of the
child as mandated by Article V of the ICPC. If the child needs to return to Michigan, the sending agency will pay the
transportation costs and will expect the full cooperation from the receiving state to accomplish this return. This
financial/medical plan will be in effect upon placement of the child in the receiving state and until proper legal
discharge consistent with the provisions of the Interstate Compact on the Placement of Children.
Worker Signature:
Supervisor’s Signature:
DHS-4334 (8-05)
1
ICPC FINANCIAL/MEDICAL PLAN
Michigan Department of Human Services
Child’s Name:
DHS Case Number #
DOB:
Check one:
male
female
FINANCIAL PLAN (check one)
Person or Facility child is to be placed with is financially able and willing to support this child.
Michigan will provide a foster board payment once the placement resource is licensed as a foster home.
Planning to apply for assistance for the child in the receiving state.
This is a return to a parent. Parent is financially responsible for the child.
Eligible to receive adoption subsidy payments from Michigan for the child.
Residential/Institutional Payment
Other – Specify:
MEDICAL PLAN (check one)
Child is IV-E eligible. The receiving state will arrange for Medicaid coverage based on the provisions of the
COBRA legislation (Title IV-E). Attached IV-E verification (DHS-352).
Child is not IV-E Eligible. The sending agency will provide a medical card and/or reimbursement for the child’s
medical expenditures incurred with prior approval. Include billing and medical emergency instructions.
Person or Facility child is to be placed with agreed to provide financially for the medical needs of the child.
This is a return to parent. Parent will provide medical for the child.
Other – Specify:
The Michigan sending agency remains ultimately financially responsible for the child and will retain jurisdiction of the
child as mandated by Article V of the ICPC. If the child needs to return to Michigan, the sending agency will pay the
transportation costs and will expect the full cooperation from the receiving state to accomplish this return. This
financial/medical plan will be in effect upon placement of the child in the receiving state and until proper legal
discharge consistent with the provisions of the Interstate Compact on the Placement of Children.
Worker Signature:
Supervisor’s Signature:
DHS-4334 (8-05)
1