Form DEO-WTP2299 "Substance Abuse and Mental Health (Samh) Treatment Verification" - Florida

What Is Form DEO-WTP2299?

This is a legal form that was released by the Florida Department of Economic Opportunity - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Florida Department of Economic Opportunity;
  • 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 DEO-WTP2299 by clicking the link below or browse more documents and templates provided by the Florida Department of Economic Opportunity.

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Download Form DEO-WTP2299 "Substance Abuse and Mental Health (Samh) Treatment Verification" - Florida

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Substance Abuse and Mental Health (SAMH) Treatment Verification
CONFIDENTIAL SENSITIVE INFORMATION – MUST BE KEPT LOCKED WHEN NOT IN USE
Section A:
SSN
_________________________________________
_____________________________
_______/_______/_______
Participant Name
Social Security Number
Date
_________________________________________
_________________________________________________
Regional Workforce Board (RWB) Designee
Public Assistance Specialist (PAS)
RWB/PAS Address: ________________________________________________________ RWB/PAS Region ______________________________
________________________________________________________ RWB/PAS Fax #: ______________________________
________________________________________ ____________________________
_____________________________________________
SAMH Provider Agency
Telephone Number
Fax Number
Section B:
Limited Work Exception for Non-Medical Incapacity Treatment Verification
The participant above is currently participating in a treatment program. The participant has completed ____ hours of treatment during the
past month, for the following weeks:
Week 1: _____/_____/_____ - _____/_____/_____ for ____ hours. Week 2: _____/_____/_____ - _____/_____/_____ for ___ hours.
Week 3: _____/_____/_____ - _____/_____/_____ for ____ hours. Week 4: _____/_____/_____ - _____/_____/_____ for ____hours.
The participant’s total hours of completion in the treatment program during the past 12 months are ________ hours.
_________________________________________
__________________________________
_____/_____/______
Name and Credentials of SAMH Counselor or Case Manager
Telephone Number
Date
Section C:
Completion of Treatment Verification
The participant indicated above has successfully completed a Mental Health/Substance Abuse Treatment Program. The months in which
the participant fully complied with the treatment requirements are circled below, totaling _____ months in a(n) ______________
__________________________________ program.
20______: January
February
March
April
May
June
July
August
September
October
November
December
20______: January
February
March
April
May
June
July
August
September
October
November
December
_________________________________________
__________________________________
_____/_____/______
Name and Credentials of SAMH Counselor or Case Manager
Telephone Number
Date
Section D:
Public Assistance Specialist Verification of Treatment Months and Receipt of Temporary Cash Assistance
The number of months verified and approved for an extension to the participant’s time limit are ___________ months.
_________________________________________
__________________________________
_____/_____/______
Public Assistance Specialist
Telephone Number
Date
Section E:
Understanding Extension Treatment Months
I understand that my time limit has been extended _________ months due to my completion of the SAMH treatment program.
____________________________________________________________________________
_____/_____/______
Participant Signature
Date
Comments: _______________________________________________________________________________________________
_________________________________________
__________________________________
_____/_____/______
_________________________________________________________________________________________________________
Regional Workforce Board Designee
Telephone Number
Date
For Official Use: This information has been disclosed to your from records protected by Federal confidentiality rules (42 CFR Part 2) and Chapters 394 and 397, Florida
Statutes. The federal and state rules prohibit you from making any further disclosure of the information unless further disclosure is expressly permitted by the written
consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2 and Chapters 394 and 397, F.S. A general authorization for the release of medical or
SAMH Treatment Verification Instructions
other information is NOT sufficient for this purpose. The Federal and state rules restrict any use of the information to criminally investigate or prosecute any substance
abuse/mental health participant. PRIVACY ACT STATEMENT: *You have not been asked to provide your social security number on this form. For your information
however, the Social Security Act (42 U.S.C. 1137) provides that your social security number may be used to administer the program, including determination of eligibility,
attributing the receipt of services, correspondence and participation, as well as for reporting purposes.
DEO-WTP 2299, May 2015 (Replaces DEO-WTP 2299, September 2012)
Substance Abuse and Mental Health (SAMH) Treatment Verification
CONFIDENTIAL SENSITIVE INFORMATION – MUST BE KEPT LOCKED WHEN NOT IN USE
Section A:
SSN
_________________________________________
_____________________________
_______/_______/_______
Participant Name
Social Security Number
Date
_________________________________________
_________________________________________________
Regional Workforce Board (RWB) Designee
Public Assistance Specialist (PAS)
RWB/PAS Address: ________________________________________________________ RWB/PAS Region ______________________________
________________________________________________________ RWB/PAS Fax #: ______________________________
________________________________________ ____________________________
_____________________________________________
SAMH Provider Agency
Telephone Number
Fax Number
Section B:
Limited Work Exception for Non-Medical Incapacity Treatment Verification
The participant above is currently participating in a treatment program. The participant has completed ____ hours of treatment during the
past month, for the following weeks:
Week 1: _____/_____/_____ - _____/_____/_____ for ____ hours. Week 2: _____/_____/_____ - _____/_____/_____ for ___ hours.
Week 3: _____/_____/_____ - _____/_____/_____ for ____ hours. Week 4: _____/_____/_____ - _____/_____/_____ for ____hours.
The participant’s total hours of completion in the treatment program during the past 12 months are ________ hours.
_________________________________________
__________________________________
_____/_____/______
Name and Credentials of SAMH Counselor or Case Manager
Telephone Number
Date
Section C:
Completion of Treatment Verification
The participant indicated above has successfully completed a Mental Health/Substance Abuse Treatment Program. The months in which
the participant fully complied with the treatment requirements are circled below, totaling _____ months in a(n) ______________
__________________________________ program.
20______: January
February
March
April
May
June
July
August
September
October
November
December
20______: January
February
March
April
May
June
July
August
September
October
November
December
_________________________________________
__________________________________
_____/_____/______
Name and Credentials of SAMH Counselor or Case Manager
Telephone Number
Date
Section D:
Public Assistance Specialist Verification of Treatment Months and Receipt of Temporary Cash Assistance
The number of months verified and approved for an extension to the participant’s time limit are ___________ months.
_________________________________________
__________________________________
_____/_____/______
Public Assistance Specialist
Telephone Number
Date
Section E:
Understanding Extension Treatment Months
I understand that my time limit has been extended _________ months due to my completion of the SAMH treatment program.
____________________________________________________________________________
_____/_____/______
Participant Signature
Date
Comments: _______________________________________________________________________________________________
_________________________________________
__________________________________
_____/_____/______
_________________________________________________________________________________________________________
Regional Workforce Board Designee
Telephone Number
Date
For Official Use: This information has been disclosed to your from records protected by Federal confidentiality rules (42 CFR Part 2) and Chapters 394 and 397, Florida
Statutes. The federal and state rules prohibit you from making any further disclosure of the information unless further disclosure is expressly permitted by the written
consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2 and Chapters 394 and 397, F.S. A general authorization for the release of medical or
SAMH Treatment Verification Instructions
other information is NOT sufficient for this purpose. The Federal and state rules restrict any use of the information to criminally investigate or prosecute any substance
abuse/mental health participant. PRIVACY ACT STATEMENT: *You have not been asked to provide your social security number on this form. For your information
however, the Social Security Act (42 U.S.C. 1137) provides that your social security number may be used to administer the program, including determination of eligibility,
attributing the receipt of services, correspondence and participation, as well as for reporting purposes.
DEO-WTP 2299, May 2015 (Replaces DEO-WTP 2299, September 2012)
SAMH Treatment Verification Instructions
The purpose for this form is to cover the legislative mandates added to Chapter 414, Florida Statutes this year regarding mental health and/or substance abuse
treatment for those receiving temporary cash assistance. This form is designed to provide the treatment verification for both the limited exception from work
activity for non-medical incapacity treatment and completion of treatment.
Section 414.065 (4)(e), F.S., Noncompliance related to outpatient mental health and substance abuse treatment. If an individual cannot participate in the
required hours of work activity due to a need to become or remain involved in outpatient mental health or substance abuse counseling or treatment, the
individual may be exempted from work activity up to 5 hours per week, not to exceed 100 hours per year. An individual may not be excused from a work
activity unless a mental health or substance abuse professional recognized by the Department or Regional Workforce Board certifies the treatment protocol
and provided verification of attendance at the counseling or treatment sessions each week.
Section 414.105 (3), F.S. A TCA recipient who is not exempt from work activity requirements and who participates in a recommended mental health or
substance abuse treatment program may earn one-month of eligibility for extended temporary cash assistance, up to a maximum of 12 additional months, for
each month in which the individual fully complies with the requirements of the treatment program. This treatment credit may be awarded only upon
successful completion of the treatment program and only once during the 48-month time limit.
Section A
This section is the confidential demographic information that is used to transfer treatment verifications through different correspondence channels. The form
originates at the SAMH treatment provider agency and information is transmitted to the Regional Workforce Board (RWB) designee for Section B during
outpatient (non-residential treatment levels) and Section C at the completion of treatment for all treatment levels. The names of the RWB designees and
Public Assistance Specialists (PAS) are provided by the TANF SAMH participants who need to investigate who their contact persons are if they don’t already
know as part of becoming economically self-sufficient.
Section B
This section is for verification of treatment to be forwarded to the RWB designee by the SAMH counselor/case manager on a weekly, bi-weekly or monthly
basis. The number of hours that the TANF SAMH client participates in “non-medical incapacity” treatment to assist with work activity completion may not
exceed 5 hours a week, and 100 hours in any 12 month period. This is known as limited work exception activity and can be used as “good cause” for not
working up to the required work activity hours assigned. Should more treatment hours be indicated, a physician’s approval for a “Medical Incapacity” is
required for any level of care.
Section C
This section is for verification of successful completion of treatment of the TANF SAMH participant by a mental health/substance abuse treatment program
director as provided in s. 414.105(3), F.S. The months in which the participant fully complied with the treatment requirements are circled and sent to the
RWB designee for credit towards each month of eligibility for temporary cash assistance, up to 12 months within the 48-month time limit.
Section D
The RWB designee makes note of the update and sends the circled months to the TANF SAMH participant’s PAS for verification that the person was indeed
receiving temporary cash assistance during those same months. The PAS then approves/disapproves the extension to the participant’s time limit based on the
participant’ eligibility status during the circled months and send it back to the RWB designee. The PAS will update the ARCA screen to include the number
of months being credited.
Section E
The RWB designee reviews the PAS’ successful treatment completion credit extension approval/disapproval with the participant and the participant signs a
statement of understanding.
DEO-WTP 2299, May 2015 (Replaces DEO-WTP 2299, September 2012)
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