Form 0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution
Effective Date: 12/1996
Institutional Staff – Part 1
This form is to be used as a notification of admission, departure, readmission or death of an applicant/recipient of Supplemental Security Income and/or medical assistance only who enters or leaves approved Title XIX sections of State institutions.
Part I is to be completed in quadruplicate by the staff of the institution's claims office. Forward the original and first copy to the Social Security district office or DPW medical eligibility worker as appropriate. Forward the second copy to the social services department of the institution. The third copy is to be retained by the person submitting the form. (Note: The third copy is retained in the institution's claims office in order that the medical assistance unit representative may obtain it during his next visit to the institution.)
Each Form 0090-I with Parts I and II completed must be filed in the permanent record of the institution.
1 — Enter name of the institution.
2 — Enter patient identifying data.
3 — If the person has moved into the section of the institution approved for title XIX purposes, complete this portion. Enter only the information contained in the institution records, or immediately available from other sources. If the patient moved from a non-approved section into the approved section of the institution, show the institution as prior address.
4 — If the person has moved from an approved section of the institution, complete this item.
5 — Enter date of entry, or leaving the medical or nursing section.
6 — Enter date of death of the individual.
7 — Enter name, relationship, address and telephone number of the individual's guardian or next of kin.
DPW Workers – Part II
For DPW medical eligibility worker to notify the institution of the action taken on the patient's application and of the amount of income available to be applied to the vendor rate for his maintenance support and treatment on those applications completed by the DPW medical eligibility worker.
As soon as initial action or a change is completed on the case, complete Part II and return the original to the claims office of the institution and retain the first copy in the applicant's/recipient's case record.
1 — Enter date referral received and applicable category.
2 — Check the appropriate box to indicate action taken. Enter effective date of action checked.
3 — If the applicant/recipient is eligible for medical assistance only and has income, enter the amount which is to be applied to his personal needs and the amount of his income available to be applied to the vendor rate for his maintenance, support and treatment. Sign and date the form.