TRACS Template Library
Table of Contents
All Program Eligibility Narrative Version 1**Page 4
All Program Eligibility Narrative Version 2**Page 11
All Program Eligibility Narrative Version 3Page15
All Program Eligibility Narrative Version 4**Page 17
ERDC Only Program Eligibility Narrative**Page21
CCB Information to DPUPage 23
Domestic Violence Assistance Agreement – TRACS SupplementPage 24
TA-DVS Eligibility and Assessment Addendum (Optional)Page 25
Interim Change Report Narrative Version 1**Page29
Interim Change Report (852) Template Version 2**Page 31
Interim Change Report Narrative Template Version 3**Page32
FS Only Eligibility Narrative**Page34
Combined ERDC and FS Narrative**Page37
BED Date Added – Benefits RestoredPage 40
Date of Request by Phone/Office ContactPage41
OHP Approval Combined with OPU No Program Available DenialPage 42
Approved Medical ApplicationPage44
No Medical Program Available Denial Page46
Duplicate/Concurrent DenialPage 47
Denied or Closed OHP Only ApplicationPage 48
EXT Eligibility DeterminationPage50
EXT Medical Quarterly Income Report Narrative Version 1Page51
EXT Medical Quarterly Income Report Narrative Version 2Page52
Medical Eligibility Template**Page 54
TRACS OHP Intake FormPage56
Medical Application/Reapplication Narrative Template**Page58
Office of Central Support (5503) Templates
5503 has a variety of special projects and project teams and processes reports for all SSP branch offices (and some SPD branches!). Included are templates for the phone bank, Children’s Medical Project Team, Breast and Cervical Cancer Program, Senior Prescription Drug Program, Address Project, Pregnancy/pregnancy loss and termination, Newborn Notifications and CHP report processing.
5503 Children’s Medical Project – Facility PlacementPage 60
5503 Children’s Medical Project – Status Change/ClosurePage 61
5503 Children’s Medical Project – DD/MFCPage 62
5503 Children’s medical Project – Eligibility ReviewPage 63
5503 Children’s Medical Project – SREL/SACPage 64
5503 Children’s Medical Project – SREL Eligibility ReviewPage 65
OHP – 5503 BCCP Approved – Pend Citizen/IdentityPage 66
OHP – 5503 BCCP Approved – Pend Citizen/Identity (version 2)Page 67
OHP – 5503 BCCP New/ApprovedPage 68
OHP – 5503 BCCP Close at RedeterminationPage 69
OHP – 5503 BCCP Redetermination ApprovedPage 70
OHP – 5503 BCCP RedeterminationPage 71
OHP - 5503 Senior Prescription Drug Program – ApprovedPage 72
OHP – 5503 Senior Prescription Drug Program – Approve/Pend for
Program FeePage 73
OHP – 5503 Senior Prescription Drug Program – ClosurePage 74
OHP – 5503 Senior Prescription Drug Program – Closure (version 2)Page 75
OHP – 5503 Senior Prescription Drug Program – DenialPage 76
OHP – 5503 Senior Prescription Drug Program – PendPage 77
OHP – 5503 BED Date Added – Benefits RestoredPage 78
OHP – 5503 Bypass End Date App CreatedPage 79
OHP – 5503 Bypass End Date Reapp ReceivedPage 80
OHP – 5503 Bypass End Date Phone ContactPage 81
OHP – 5503 Pregnancy NotificationPage 82
OHP – 5503 Notification to Branch of PregnancyPage 83
OHP – 5503 Notification of Pregnancy Loss/TerminationPage 84
OHP – 5503 Notification to Branch of Pregnancy Loss/TerminationPage 85
OHP – 5503 Newborn Added to CasePage 86
OHP – 5503 Notification to Branch of NewbornPage 87
OHP – 5503 UF/AF Report ChangePage 88
OHP – 5503 Notification to Branch of UF-FA Report ChangePage 89
OHP – 5503 DCS Sanction AppliedPage 90
OHP – 5503 Change to CasePage 91
OHP – 5503 Change of AddressPage 92
OHP – 5503 Notification to Branch of Address ChangePage 93
OHP – 5503 OHP Reopen/Restore MedicalPage 94
OHP – 5503 Unable to Restore DU Closed CasePage 95
OHP – 5503 148 SentPage 96
OHP – 5503 Health Insurance Premium Reimbursement (HIP)Page 97
OHP – 5503 OHP Client has or is Eligible for Medicare – ClosurePage 98
OHP – 5503 CHIP with TPR ClosurePage 99
OHP – 5503 CWM no CHIP ClosurePage 100
OHP – 5503 Medical Case Closed Per Client RequestPage 101
OHP – 5503 Case TransferPage 102
OHP – 5503 Companion Case TransferPage 103
OHP – 5503 FS Companion Case TransferPage 104
OHP – 5503 5503 Medical Transportation Page 105
OHP – 5503 415H Sent to ClientPage 106
OHP – 5503 Hearing Request Sent to ClientPage 107
All Program Eligibility Narrative Version 1
1) General Application Information
a)Program(s) Applying For:
b)Case Number(s):
c)Date of Request:
d)Filing Date for FS:
e)Type of Interview/Contact (FTF, Mail, Phone, HV) and date:
F)receiving tribal TANF OR FOODBENEFITS?:
g)expedited fs service (y/n and reason):
h)Alternate Format/Language:
i)Authorized Rep/Alternate Payee Name (231 or 7218 completed?) ID FOR FS AUTH REP AND ALL ALT PAYEES Verified by?:
j)does client want to register to vote? (MSC 0503):
k)Child Welfare Involvement? Consider for employment plans, if any:
l)Disability? Does anyone need an accommodation?
(For medical program Accommodations, call a medical program analyst.):
m)Release of Information Form Completed?:
n)Referrals?:
2) Non-Financial Requirements/Information
A) Eligibility Groups:
i)Who is applying together?
ii)Who must apply together?
iii) Does everyone share food in the
HOusehold?
iv)Is anyone pregnant? If so, what is the due date?
Is the father of the unborn in the household?
b)ID:
c) Citizen/Alien Status (explain eligibility):
i)WAived for TANF/TA-DVS due to domestic violence (Y/N)
ii)Is anyone required to meet DRA citizenship documentation (Y/N)
(List who needs documentation; what documents were used to verify ID and citizenship for each person; Cit field information)
d) SSN (how verified?):
e) Residency (Oregon resident, not questionable?):
f) Cooperation with DCS (including CASH medical support):
i)Absent Parents/FLS 112 (112 is not required for medical applicants)?
ii)Father of UB, if not in household?
iii)Good Cause for noncooperation with child support (428A/8660)?
iv)Send address of record or claim of risk information to DCS?
g) Deprivation (needed for TANF, MAA, MAF):
i)Who is the caretaker relative(s)? If because of UB only, what is DUE?
ii)Waived pregnancy final month requirement for TANF/TA-DVS due to DV?
iii)Who is the PWE for two-parent based on UN?
iv)Did PWE quit job within last 12 months? If yes, was there good cause?
v)What is incapacity for two-parent based on incapacity? How verified?
vi)For TANF/MAA/MAF continued absence, how verified?
h)Student Status (explain eligibility for FS, TANF and OHP-OPU):
i)For OHP-OPU Only, Premium Requirement?:
j) pursuit of assets:
i) Existing or available health insurance? 415H and copies of health insurance cards to HIG?
ii)UC?
3) Financial Requirements/Information
a)Shelter (who is paying? how much?):
b)Utilities (justify standard used):
c) Resources (for TANF/MAA/MAF/OHP-OPU/OHP-CHP and FS non-categorically eligible household, including vehicles):
d) Income:
i)Earned Income (actual/anticipated/converted & how verified?):
ii) Screen Data:
WAGE
WORK #
DPPL
HINQ/SSNX
PESM, P
***Show Earned Income Calculation
iii) FS:
iv)ERDC:
v)MAA/TANF:
vi)TA-DVS (count only income immediately available):
vii)MAF:
viii)QMB:
ix)Other:
x)Medical Cost (FS only, for elderly/disabled, how verified?)
xi)Unearned Income (actual/anticipated/converted & how verified?)
xii)screen data:
ECLM
SMUX/SMR1
***Show Unearned Income Calculation
xii)FS:
xiv)ERDC:
xv)MAA/TANF:
xvi)TA-DVS (count only income immediately available):
xvii)MAF:
xviii)QMB:
xix)Other:
e)OHP Income Calculation (include need group size, self-employment issues):
DOR
Budget month used
Budget month income
Income one month prior to budget month
Income two months prior to budget month
Income three months prior to budget month
Three month average (list 3 months used for average)
Self-employed? 50% deduction or actual allowable deductions?
Equal to or less than 10% FPL for non-exempt OPU applicants?
f)For FS Only:
1
Step 1/Step 2 for NC2s with Income
Medical Cost (for elderly/disabled; how verified; none claimed?)
Court Ordered Support (NAME child outside of HH, how verified?)
G)Categorical EligibIlITYfor FS:
Income Under 185% FPL?
3400 Given?
If Not CAT EL, Why?
h)Child/Dependent Care Cost:
Ongoing Copay:
Reduced Copay (RCP) Month?
Child Care Hours:
Child Care Providers:
Immunization Records:
i)If Zero Income, How are Applicants Meeting Basic Needs? IF HELP FROM FAMILY/FRIENDS, WHAT FORM OF HELP AND HOW VERIFIED?:
4) FS Employment Requirements
a)30-day Job Quit for FS (good cause?):
b)OFSET Status/Plan (if exempt/disqualified, why)?:
5) TANF JOBS Status/Plan (DHS 7823/SIGNED 7819)
(No JOBS Requirement for MAA/MAF)
6) TA-DVS/TANF When Risk of Domestic Violence
Do not use this addendum on-line if you have any concerns about access by other DHS or partner agencies.
DO NOT COMPLETE THIS FORM ON-LINE IF:
* THE ABUSER LIVES IN THE HOUSEHOLD, OR
* IF YOU BELIEVE THE ABUSER HAS ACCESS TO TRACS.
a) Immediate safety assessed within 8 working hours (Y/N):
b)List safety concerns:
c)Abuser's name:
d)Requirements waived for TANF/TA-DVS Due to Domestic Violence (Cannot be waived for MAA):
e)DVAA (1543) Completed or Scheduled to Be Completed (Date):
f)Resources Offered until DVAA Can Be Completed:
7) Eligibility Decision:
a)Pended
i)Why?
ii)What is the 30th/45th day?
iii)Was BED coding added to prevent automatic closure of medical or TANF?
iv)CID, CIE, CIP needed for medical?
b)Denied
i)Why?
ii)462/456 notices sent?
iii)If the client is disabled and medical denied, was OSIPM presumptive referral made to SPD? to what branch?
c) Approved:
i)FS:
Effective date?
When does the cert end?
Reporting method?
ii)TANF:
What is the next review date?
Reporting method?
Referred for SFPSS?
iii)MAA:
What is the next review date?
When was each person’s medical started?
If the medical start date is different from the DOR, why?
Is there any retroactive medical eligibility?
Reporting method?
Managed health plan or PCM?
iv)MAF:
What is the next review date?
When was each person’s medical started?
If the medical start date is different from the DOR, why?
Is there any retroactive medical eligibility?
Reporting method?
Managed health plan or PCM?
v)ERDC:
What is the next APR date?
What is the reduced co-pay month (RCP)?
What is the ongoing co-pay?
vi)TA-DVS:
90 day eligibility period from______to______.
Second or subsequent request within 12 month period (Y/N):
If yes, staffed with central office (Y/N).
If approved, 456DV given (Y/N):
If denied, 456 given with denial reason of:
vii)OHP:
Certification period for each person?
When was each person’s medical started?
If the medical start date is different from the DOR, why?
Managed health plan or PCM?
d)Other Program(s): Approved? Pended? Denied (462/456)? Why?
8) Additional Comments:
All Program Eligibility Narrative Version 2
1)General Application Information
a)Program(s) Applying for:
b)Case number(S):
c)Date of request:
d)Filing Date for FS:
e)Type of Interview/Contact (FTF, Mail, Phone, HV) and date:
f)Eligible for Tribal tanF OR FOOD BENEFITS?:
G)Expedited FS Service (Y/N & Reason):
H)Alternate Format/Language:
I)Authorized Rep/Alternate Payee Name (231 or 7218 completed?). ID FOR FS AUTH REP AND ALL ALT PAYEES VERIFIED BY?:
J)Remember to explain to clients about Voter Registration (MSC 0503):
K)Child Welfare Involvement:
L)Disability? Does anyone need an accommodation?
For medical program Accommodations, call a medical program analyst.:
M)Release of Information Form Completed?:
N) Referrals:
2)Non-Financial Requirements/Information
A) Eligibility Groups:
i)Who is applying together?
ii)Who must apply together?
iii) Does everyone share food in the
HOusehold?
iv)Is anyone pregnant? If so, what is the due date?
B)ID:
C)Citizenship/Alien Status: Waived for TANF/TA-DVS for domestic violence? (List who needs documentation; what documents were used to verify ID and citizenship for each person; Cit field information)
D)SSN (how verified?):
E)Residency (Oregon resident, not questionable?)
F)Cooperation with DCS (including cash medical support):
G)Deprivation (Needed for TANF, MAA, MAF):
H)Student Status (explain eligibility for FS, TANF and OHP- OPU):
I)For OHP-OPU Only, Premium Requirement?:
J)TPR?
3)Financial Requirements/Information
(a)Shelter (Who is paying? How much?)
(b)Utilities (JUSTIFY STANDARD USED)
(c)Resources (for TANF/MAA/MAF/OHP-OPU/OHP-CHP and FS non-categorically eligible household, including vehicles):
(d)Income
Earned Income (actual/anticipated & how verified?):
(i)Screen Data:
WAGE:
WORK #:
DPPL:
HINQ / SSNX:
PESM, P:
***Show earned income calculation for each program:
Unearned Income (actual /anticipated & how verified?):
(ii)screen data:
ECLM
SMUX, SMR1
***Show unearned income calculation for each program:
(E)OHP Income Calculation (Include Need Group Size, Self-employment issues)
Show Calculation:
Budget Month?
3 Month Average?
(F)For FS Only:
Step 1 / Step 2 For NC2s With Income:
Income Under 185% FPL?
dHS 3400 GIVEN?
IF NOT CAT EL, WHY?
Court Ordered Support (NAME child outside of HH, how verified?)
Medical Costs?
(g)Child / Dependent Care Cost:
On-going Copay:
Reduced Copay (RCP) for This Month?
Child Care Hours:
Child Care Providers:
Immunization Records:
(H)If Zero Income, How Meeting Basic Needs? IF HELP FROM FAMILY/FRIENDS, HOW IS HELP RECEIVED AND HOW VERIFIED?
4)FS Employment Requirements
30-Day Job Quit For FS (Good Cause?):
OFSET Status / Plan (If Exempt/Disqualified, Why?):
5)Jobs Status/Plan/Include TA-DVS
6)TANF When Risk for DV:
7)Eligibility Decision
Food Stamps:
TANF:
ERDC:
MAA / MAF:
OHP:
Other Medical Program:
OHP Cert Period/MAA/MAF (or Other Medical) Review Date?
Health insurance Information (Plans Chosen; HNA?)
Reporting System(s):
Pended For:
Denied:
8)Additional Comments:
All Program Eligibility Narrative Version 3
1)General Application Information
Explain the circumstances (what/why are they applying, who is applying, is anyone pregnant, what’s the DOR/filing date, alternate format, language)?
2)Non-Financial Requirements/Information
ID
Citizen/Alien Status
SSN
Residency
Eligibility groups
DCS Cooperation (including Cash medical support)
Deprivation
Student Status
3)Non-Financial Requirements/Information & TA-DVS TANF when risk of domestic violence
4)Financial Requirements/Information
Shelter
Utilities
Resources
Income (earned and unearned, pay dates, YTD totals)
FS child care DEDUCTION
FS medical DEDUCTION
FS COURT-ORDERED SUPPORT DEDUCTION
Categorically eligible for FS?
5)FS Employment Requirements & TANF JOBS Status/Plan
JOBS/OFSET?
6 )Eligibility Decision (include next Review/Recert Date)
Reporting Method
Health Plan
Forms
ALL PROGRAM ELIGIBILITY NARRATIVE VERSION #4
1)GENERAL APPLICATION/NON-FINANCIAL INFORMATION
A.PROGRAM(S) APPLYING FOR:
B.CASE NAME:
C.CASE NUMBER(S):
D.DATE OF REQUEST:
E.FILING DATE:
F.INTERVIEW DATE:
G.TYPE OF INTERVIEW (FTF, MAIL, PHONE, HV):
H.ALTERNATE FORMAT/LANGUAGE:
I.EXPEDITED FS SERVICE (Y/N & REASON):
J.AUTHORIZED REP/ALTERNATE PAYEE NAME (231/7218 COMPLETED?). ID FOR FS AUTH REP AND ALL ALT PAYEES VERIFIED BY?:
2)HOUSEHOLDCOMPOSITION/CITIZENSHIP/ID/SSN/RESIDENCY
A.WHO’S IN HH?:
B.filing group(s)?:
C.Fleeing felon (FS & TANF only):
d.ANYONE PREGNANT? WHO AND DUE DATE?:
e.ID (DOES IT MEET FS AND MEDICAID REQUIREMENTS?:
f.CITIZENSHIP STATUS:
WHO NEEDS TO MEET DRA CITIZENSHIP REQUIREMENTS?:
DOCUMENTS USED FOR CITizenSHIP AND ID (LIST BY PERSON):
ARE CIT FIELDS UPDATED FOR ALL?:
G.alien status?:
H.SSN (ALIAS SSN?):
I.RESIDENCY:
J.TRIBAL verification?:
Receiving any Tribal benefits?:
Enroll in medical/dental plan?:
K.STUDENT STATUS:
3)HOUSEHOLD INCOME
A. EARNED INCOME:
WAGE:
DPPL:
HINQ/SSNX/PESM (PESM,P,provider # enter):
THE WORK NUMBER:
SHOW EARNED INCOME CALCULATION:
B.UNEARNED INCOME:
ECLM:
SMUX/SMR1:
grant:
SHOW UNEARNED INCOME CALCULATION:
C.IF ZERO INCOME, HOW MEETING BASIC NEEDS?:
(IF STATES HELP FROM FAMILY/FRIENDS, WHAT IS THE FORM OF THIS HELP? HOW WAS IT VERIFIED?):
4)FOOD STAMPS
A.STEP 1/STEP 2 FOR NC2'S WITH INCOME:
B.3400 GIVEN?:
C.INCOME UNDER 185% FPL?:
D.CAT ELIG? IF NO, WHY?:
e.30-DAY JOB QUIT FOR FS (GOOD CAUSE?):
f.OFSET STATUS/PLAN (IF EXEMPT/DISQUALIFIED, WHY?):
5)FOOD STAMP DEDUCTIONS
A. SHELTER (WHO IS PAYING? HOW MUCH?):
B.UTILITIES:
C.COS (FOR CHILD OUTSIDE OF HH, HOW VERIFIED?):
D.MEDICAL COSTS (FOR ELDERLY/DISABLED, HOW VERIFIED? AMOUNTS?):
E.CHILDCARE COSTS:
6)ERDC and TANF CHILDCARE
A.CHILD/DEPENDENT CARE COST:
B.COPAY: rcp month?:
C.OTHER COSTS NOT PAID BY DHS:
D.CHILD CARE HOURS:
E.IMMUNIZATIONS UP TO DATE:
F.PROVIDER NAME AND NUMBER:
7)TANF/MAA/MAF
A.BASIS OF DEPRIVATION:
B.ABSENT PARENTS:
C.PWE (WHO AND HOW DETERMINED):
D.12-MONTH JOB QUIT FOR TANF (GOOD CAUSE?):
E.PURSUING ASSETS?
F.DISABLED (Who, how; documented):
G.BUDGET MONTH?:
H. TANF ONLY (DOESN’T AFFECT MEDICAL): FLEEING FELON?:
8)CHILD WELFARE INVOLVEMENT?
9)TANF JOBS MANDATORY?
A.PLAN (7823/7819 signed?):
10)TA-DVS/TANF WHEN RISK OF DOMESTIC VIOLENCE
A. IMMEDIATE SAFETY ASSESSED WITHIN 8 WORKING HOURS (Y/N):
B. LIST SAFETY CONCERNS:
C. ABUSER S NAME:
D.REQUIREMENTS WAIVED FOR TANF/TA-DVS DUE TO DV (CANNOT BE WAIVED FOR MAA):
E. DVAA (1543) COMPLETED OR SCHEDULED TO BE COMPLETE (DATE)?:
F. RESOURCES OFFERED UNTIL dVAA CAN BE COMPLETED?:
G)Beginning date TA-DVS eligibility:
H)End date TA-DVS eligibility:
I)Staffed with______(Name of Analyst)if TA-DVS received within the last 12 months.
11)MEDICAL (REVIEW FOR MAA/MAF FIRST AS ABOVE, THEN OHP)
A.BUDGET MONTH? (START WITH DOR MONTH AND “FLOAT” BUDGET MONTH IF NECESSARY):
B.SELF-EMPLOYED? USING 50%/ OR ACTUAL DEDUCTIONS?:
C.GROSS INCOME FOR BUDGET MONTH:
D.GROSS INCOME FOR LAST MONTH:
E.GROSS INCOME FOR 2 MONTHS AGO:
F.GROSS INCOME FOR 3 MONTHS AGO:
G.3-MONTH AVERAGE:
H.EQUAL TO OR LESS THAN 10% FPL FOR NON-EXEMPT OPU?:
12)FOR ALL MEDICAL
A.ENROLLMENT:
B.TPR/ESI AVAILABLE?:
C.415H COMPLETED AND SENT TO HIG? GROUP INSURANCE FORM 422-091 TO FHIAP?:
D.pursuit of assets:
e.HIP?:
13)RESOURCES (FOR TANF/MAA/MAF/OPU/CHP AND FS NON-CAT)
A.CHECKING:
BSAVINGS:
C.OTHER:
D.VEHICLE (WVIR):
14)PENDED FOR? INCLUDE PROGRAM(S) AND date(s) DUE
15)ELIGIBILITY DECISION/CERT PERIOD:
A.FOOD STAMPS:
B.TANF:
C.ERDC:
D.MAA/MAF:
E.OHP:
F.OTHER MEDICAL PROGRAM:
G. TA-DVS:
16)GENERIC INFORMATION
A.DOES CLIENT WANT TO REGISTER TO VOTE?:
B.REPORTING SYSTEM ASSIGNED:
C.RELEASE OF INFO OBTAINED:
D.APPLICATION SIGNED, DATED AND IN FILE?:
E.REFERRALS:
17)ADDITIONAL COMMENTS:
ERDC ONLY PROGRAM ELIGIBILITY NARRATIVE
1)NAME:
2)CASE NUMBER:
3)DATE OF REQUEST:
4)INTERVIEW DATE:
5)TYPE OF INTERVIEW (FTF, MAIL, PHONE, HV):
6)RESIDENCY:
7)ALTERNATE FORMAT/LANGUAGE:
8)AUTHORIZED REP/ALTERNATE PAYEE NAME (231 COMPLETED?)
9)HOUSEHOLD COMPOSITION (LIST EVERYONE IN THE HOUSEHOLD):