Form 223 Attachment A "Medicaid and IV-E Application" - Georgia (United States)

What Is Form 223 Attachment A?

This is a legal form that was released by the Georgia Department of Juvenile Justice - a government authority operating within Georgia (United States). Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the Georgia Department of Juvenile Justice;
  • 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 223 Attachment A by clicking the link below or browse more documents and templates provided by the Georgia Department of Juvenile Justice.

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Download Form 223 Attachment A "Medicaid and IV-E Application" - Georgia (United States)

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GEORGIA DEPARTMENT OF HUMAN SERVICES
Medicaid and IV-E Application
This form is to be completed by JPPS or Case Expeditor for screened or expedited DJJ youth detained and awaiting out-of home placement or
placed in out-of-home placement.
Youth’s
Name:_________________________________________________
SSN: ________________________________
DOB: ________________ Gender: M F
Race: ______ US Citizen or Qualified Alien/Immigrant: Y
N
Note: Attach copy of Birth Certificate or Homeland Security documentation.
Youth’s Mother: _______________ _________________________
SSN: ____________________________ Race:
DOB: ____________
Address:
City, State, Zip: _________________________________________
Youth’s Father: __________________________________________ SSN: ________________________
Race:
DOB: ____________
ο
ο
Address: _______________________________________
City, State, Zip: __________________________
Legal father
Putative Father
ο
ο
ο
ο
ο
ο
ο
Parents are:
Married
Never Married
Separated
Divorced
Has paternity been established?
Yes
No
Unknown
ο
ο
Date Detained/Placed: ___________________
Joint DJJ/DFCS custody?
Yes
No
ο
ο
MEDICAID INFORMATION
: Prior Months Medicaid Needed?
Yes
No Month: ____________
1. Does this youth receive any income? οYes ο No Indicate type of income: ___ SSI
___ RSDI
___ Child Support
If yes, please indicate amount and frequency:
$ ______________/_______ ___ Other (explain) _____________________
2. Does this youth have any resources (Bonds, Cash, Savings/Checking Account, Car, etc.)? ο Yes ο No
If yes, indicate type and amount:
______________________
$ ___________________
3. Is the youth pregnant? ο Yes οNo Verified and documented? ο Yes οNo
Estimated Delivery Date: ___________
4. Is the youth covered by health insurance other than Medicaid/PeachCare? ο Yes ο No
If yes, name of insurance company: ____________________________
Group/ID #: _______________________________
Name of insured: _______________________________ Relationship to youth: _____________
Attach front and back copy
of insurance card.
IV-E INFORMATION:
SUBMIT ALL COURT ORDERS & COMPLAINTS/PETITIONS WITH APPLICATION IF NOT SCANNED IN JTS
4a. List the name of the person with whom the youth was living with at time of removal:______________________________
b.
Is this a ____parent ____relative____other? If relative or other, specify relationship :_____________________________
c.
In the complaint/petition, who is identified as having custody? __________________________________
d.
Is the person named in 4c the same person as in 4a? ____Yes _____No If no, did the youth live with the person in 4c within the 6
months prior to removal from the home? ____Yes ____ No If yes, list the months: ________________________________
List everyone living in the home at time youth was removed:
Name
DOB
Relationship to child
Gender Race
SSN
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
___________________
___
____
_______________________
*Please list additional members on separate page.
5.
A. Is either parent absent from home? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
B. Is either parent deceased? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
C. Is either parent disabled/incapacitated? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
D. Is either parent unemployed? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
6. Name and address of current placement:
____________________________________________________
Indicate type of placement: ___Group Home ___CCI
____________________________________________________
___CPA ___RYDC ___Wilderness ___A&D ___PRTF ____________________________________________________
7. Legal Information: Date of Juvenile Court complaint/petition: ____________________
Date of court hearing addressing complaint/petition: ____________________ Judge’s Name: ______________________________
ο Yes
ο No
a. Does this court order contain “contrary to welfare/best interest” language with child specifics?
b. Is there a court order that addresses “reasonable efforts to prevent removal” with agency specifics obtained within 60 days of
οNo Date of court hearing: ____________________ Judge’s Name: ___________________________
οYES
child’s removal?
JPPS Signature: _______________________________________________ Date: ________________________
___________________________________
Eligibility Specialist Signature
Date Received: ________________
DJJ 24.1 Attachment A: Form 223 DJJ (Rev. 5/2013)
GEORGIA DEPARTMENT OF HUMAN SERVICES
Medicaid and IV-E Application
This form is to be completed by JPPS or Case Expeditor for screened or expedited DJJ youth detained and awaiting out-of home placement or
placed in out-of-home placement.
Youth’s
Name:_________________________________________________
SSN: ________________________________
DOB: ________________ Gender: M F
Race: ______ US Citizen or Qualified Alien/Immigrant: Y
N
Note: Attach copy of Birth Certificate or Homeland Security documentation.
Youth’s Mother: _______________ _________________________
SSN: ____________________________ Race:
DOB: ____________
Address:
City, State, Zip: _________________________________________
Youth’s Father: __________________________________________ SSN: ________________________
Race:
DOB: ____________
ο
ο
Address: _______________________________________
City, State, Zip: __________________________
Legal father
Putative Father
ο
ο
ο
ο
ο
ο
ο
Parents are:
Married
Never Married
Separated
Divorced
Has paternity been established?
Yes
No
Unknown
ο
ο
Date Detained/Placed: ___________________
Joint DJJ/DFCS custody?
Yes
No
ο
ο
MEDICAID INFORMATION
: Prior Months Medicaid Needed?
Yes
No Month: ____________
1. Does this youth receive any income? οYes ο No Indicate type of income: ___ SSI
___ RSDI
___ Child Support
If yes, please indicate amount and frequency:
$ ______________/_______ ___ Other (explain) _____________________
2. Does this youth have any resources (Bonds, Cash, Savings/Checking Account, Car, etc.)? ο Yes ο No
If yes, indicate type and amount:
______________________
$ ___________________
3. Is the youth pregnant? ο Yes οNo Verified and documented? ο Yes οNo
Estimated Delivery Date: ___________
4. Is the youth covered by health insurance other than Medicaid/PeachCare? ο Yes ο No
If yes, name of insurance company: ____________________________
Group/ID #: _______________________________
Name of insured: _______________________________ Relationship to youth: _____________
Attach front and back copy
of insurance card.
IV-E INFORMATION:
SUBMIT ALL COURT ORDERS & COMPLAINTS/PETITIONS WITH APPLICATION IF NOT SCANNED IN JTS
4a. List the name of the person with whom the youth was living with at time of removal:______________________________
b.
Is this a ____parent ____relative____other? If relative or other, specify relationship :_____________________________
c.
In the complaint/petition, who is identified as having custody? __________________________________
d.
Is the person named in 4c the same person as in 4a? ____Yes _____No If no, did the youth live with the person in 4c within the 6
months prior to removal from the home? ____Yes ____ No If yes, list the months: ________________________________
List everyone living in the home at time youth was removed:
Name
DOB
Relationship to child
Gender Race
SSN
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
__________________
___
____
_______________________
_______________________________
_______
___________________
___
____
_______________________
*Please list additional members on separate page.
5.
A. Is either parent absent from home? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
B. Is either parent deceased? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
C. Is either parent disabled/incapacitated? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
D. Is either parent unemployed? ___Yes ___No
Which Parent? ___Mother ___Father ___Both
6. Name and address of current placement:
____________________________________________________
Indicate type of placement: ___Group Home ___CCI
____________________________________________________
___CPA ___RYDC ___Wilderness ___A&D ___PRTF ____________________________________________________
7. Legal Information: Date of Juvenile Court complaint/petition: ____________________
Date of court hearing addressing complaint/petition: ____________________ Judge’s Name: ______________________________
ο Yes
ο No
a. Does this court order contain “contrary to welfare/best interest” language with child specifics?
b. Is there a court order that addresses “reasonable efforts to prevent removal” with agency specifics obtained within 60 days of
οNo Date of court hearing: ____________________ Judge’s Name: ___________________________
οYES
child’s removal?
JPPS Signature: _______________________________________________ Date: ________________________
___________________________________
Eligibility Specialist Signature
Date Received: ________________
DJJ 24.1 Attachment A: Form 223 DJJ (Rev. 5/2013)