Basic Care Resident Payment Menu

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: Z

TECS CLIENT ID: ______

RESIDENT PAYMENT MONTH: ____ (MMYY / OPTIONS 'A','B','D','F')

ADD RESIDENT SELECT OPTION ‘ A’

N. D. DEPARTMENT OF HUMAN SERVICES

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

‘C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

‘E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: A

TECS CLIENT ID: 123456____

RESIDENT PAYMENT MONTH: 1209 (MMYY / OPTIONS 'A','B','D','F')

ADD RESIDENT SCREEN

N. D. DEPARTMENT OF HUMAN SERVICES

TECS CLIENT ID: 0000556412

RESIDENT NAME: MOUSE MICKEY__ _ (LAST,FIRST,MI) SSN: 000-00-0000

BIRTHDATE: 11081928

PERSONAL CARE RATE:$54.79 ROOM/BOARD RATE:$39.39 TOTAL RATE:$94.18

PROVIDER MEDICAID NUMBER:30778___ CURRENT RATE:$

FACILITY: EFFECTIVE DATE:

ADDRESS:

CITY: STATE: ZIP:

BCAP ELIGIBILITY START DATE:011210 MEDICAID REDETERMINATION DUE DATE:010111

FIRST FUNCTIONAL ASSESSMENT DATE: 011210

CURRENT FUNCTIONAL ASSESSMENT DATE:

WORKER NAME: DAISY D., EW I______WORKER COUNTY: 18

PRESS 'ENTER' TO ADD PRESS 'PF3' TO RETURN TO MENU

ADD RESIDENT PAYMENT SELECT OPTION ‘ B’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: B

TECS CLIENT ID: 1234______

RESIDENT PAYMENT MONTH: 011210____ (MMYY / OPTIONS 'A','B','D','F')

ADD RESIDENT PAYMENTSCREEN

PAYMENT MONTH

011210 N. D. DEPARTMENT OF HUMAN SERVICES

ADD BASIC CARE MONTHLY RESIDENT PAYMENT

TECS CLIENT ID: 000000000 RESIDENT NAME: MOUSE MICKEY

SSN: 000-00-0000 BIRTHDATE: 11081928 AGE: 80

FACILITY: TUFTE MANOR CITY: GRAND FORKS STATE: ND

PERSONAL CARE RATE:$32.28 ROOM/BOARD RATE:$ 34.23 TOTAL RATE:$ 66.51

BCAP ELIG START DATE: 090310 MEDICAID REDETERMINATION DUE DATE: 093011

CLOSING EFFECTIVE DATE: CURRENT FUNCTIONAL ASSESSMENT DATE: 091010

WORKER NAME: Jane, EW I WORKER COUNTY: 18

PAYMENT MONTH: 0409 RESIDENT PAYMENT AMT: $155.37 PHYSICAL COUNTY: 18

GROSS INCOME DEDUCTIONS

SSI : ______CLOTHING/PERSONAL : 85.00

SSA : ____ 490.40 MEDICARE PREMIUM : _____96.40

VA : ______HEALTH INSURANCE : ____153.63

OTHER : ______: ______

TOTAL:$ 490.40 TOTAL:$ 335.03

RECIPIENT RESPONSIBILITY: $155.37

PRESS 'ENTER' TO ADD PRESS 'PF3' TO RETURN TO MAIN MENU

CHANGE RESIDENT INFORMATION SELECT OPTION ‘ C’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: C

TECS CLIENT ID: 1234______

RESIDENT PAYMENT MONTH: ______(MMYY / OPTIONS 'A','B','D'

CHANGE RESIDENT INFORMATION

TECS CLIENT ID: 0000556412

RESIDENT NAME: MOUSE MICKEY (LAST,FIRST,MI) SSN: 000-00-0000

BIRTHDATE: 11081928

PERSONAL CARE RATE:$ ROOM/BOARD RATE:$ TOTAL RATE:$

PROVIDER MEDICAID NUMBER:30778___ CURRENT RATE:$

FACILITY: EFFECTIVE DATE:

ADDRESS:

CITY: STATE: ZIP:

BCAP ELIGIBILITY START DATE:090110 MEDICAID REDETERMINATION DUE :093011

FIRST FUNCTIONAL ASSESSMENT DATE: 011210

CURRENT FUNCTIONAL ASSESSMENT DATE: 090210

WORKER NAME: DAISY D., EW I______WORKER COUNTY: 18

CLOSING EFFECTIVE DATE: 10012010___

PRESS 'ENTER' TO ADD PRESS 'PF3' TO RETURN TO MENU

CHANGE MONTHLY RESIDENT PAYMENT SELECT

OPTION ‘ D’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

‘E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: D

TECS CLIENT ID: 1234______

RESIDENT PAYMENT MONTH: 011210____ (MMYY / OPTIONS 'A','B','D'

“D” Change Monthly Resident Payment

Note - Update BCAP when the RL changes for the future month

N. D. DEPARTMENT OF HUMAN SERVICES

CHANGE BASIC CARE MONTHLY RESIDENT PAYMENT

TECS CLIENT ID: 0000000000 RESIDENT NAME: MOUSE MICKEY

SSN: 000-00-0000 BIRTHDATE: 11081928 AGE: 80

FACILITY: ST ANNE'S GUEST HOME CITY: GRAND FORKS STATE: ND

PERSONAL CARE RATE:$ 20.09 ROOM/BOARD :$ 42.77 TOTAL RATE:$ 62.86

BCAP ELIG START DATE: 020399 MEDICAID REDETERM DUE DATE: 063010

CLOSING EFFECTIVE DATE: CURRENT FUNCTIONAL ASSESS DATE: 060709

WORKER NAME: DAISY D, EW1 WORKER COUNTY: 18

PAYMENT MONTH: 0509 RESIDENT PAYMENT AMT: $ 861.59 PHYSICAL COUNTY: 18

GROSS INCOME DEDUCTIONS

SSI : ______CLOTHING/PERSONAL : 85.00

SSA : ___1171.40 MEDICARE PREMIUM : ____96.40

VA : ______RESCRIPTION COPAY : ___15.50

OTHER : ______RECIPIENT LIABILITY : ____112.91

TOTAL:$ 1171.40 TOTAL:$ 309.81

RECIPIENT RESPONSIBILITY:$ 856.70

PRESS 'ENTER' TO CHANGE PRESS 'PF3' TO RETURN TO MENU

INQUIRE ON A RESIDENT SELECT OPTION ‘ E’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: E

TECS CLIENT ID: 1234______

RESIDENT PAYMENT MONTH: ______(MMYY / OPTIONS 'A','B','D'

N. D. DEPARTMENT OF HUMAN SERVICES

BASIC CARE RESIDENT INQUIRY

TECS CLIENT ID: 000011375

RESIDENT NAME: CLAUS SANTA SSN: 000-00-0000

BIRTHDATE: 012011809 AGE: 200

PERSONAL CARE RATE:$ 44.47 ROOM/BOARD RATE:$ 34.54 TOTAL RATE:$ 79.01

FACILITY: NORTH POLE CARE CENTER CURRENT RATE:$ 79.01

ADDRESS: 301 RAINDEER LANE EFFECTIVE DATES: 07012009

CITY: NORTH POLE STATE: ND ZIP: 58000

BCAP ELIGIBILITY START DATE: 090110 MEDICAID REDETERMINATION DUE DATE: 093011

FIRST FUNCTIONAL ASSESSMENT DATE: 090110

CURRENT FUNCTIONAL ASSESSMENT DATE:

WORKER NAME: COUNTY EW WORKER COUNTY: 08

CLOSING EFFECTIVE DATE:

PRESS 'PF3' TO RETURN TO MENU

INQUIRE ON MONTHLY RESIDENT PAYMENT SELECTOPTION ‘ F’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: F

TECS CLIENT ID: 1234______

RESIDENT PAYMENT MONTH: 122009 (MMYY / OPTIONS 'A','B','D'

N. D. DEPARTMENT OF HUMAN SERVICES

BASIC CARE MONTHLY RESIDENT PAYMENT INQUIRY

TECS CLIENT ID: 00001137 RESIDENT NAME: CLAUS SANTA

SSN: 000-00-0000 BIRTHDATE: 122221908 AGE: 200

FACILITY: NORTH POLE CARE CENTER CITY: NORTH POLE STATE: ND

PERSONAL CARE RATE: $ 44.47 ROOM/BOARD RATE:$ 34.54 TOTAL RATE:$ 79.01

BCAP ELIGIBILITY START DATE: 051101 MEDICAID REDETERMINATION DUE DATE: 100110

CLOSING EFFECTIVE DATE: CURRENT FUNCTIONAL ASSESSMENT DATE: 090111

WORKER NAME: COUNTY EW WORKER COUNTY: 03

PAYMENT MONTH: 1109 RESIDENT PAYMENT AMT:$ 576.19 PHYSICAL COUNTY: 03

GROSS INCOME DEDUCTIONS

SSI : 71.00 CLOTHING/PERSONAL : 60.00

SSA : 623.00 CO-PAY : 42.61

VA : HUMANA HEALTH INS : 15.20

OTHER : :

TOTAL:$ 694.00 TOTAL:$ 117.81

RECIPIENT RESPONSIBILITY:$ 576.19

PRESS 'PF3' TO RETURN TO MENU

DELETE RESIDENT (STATE ONLY) OPTION ‘ G’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION:

TECS CLIENT ID: ____

RESIDENT PAYMENT MONTH: ____ (MMYY / OPTIONS 'A','B','D','F')

If you attempt to delete the resident, you will receive the following information:

NEXT SB6810 LIB=SS

SB6810 0520 NAT0963 Security violation during program execution (SB6818).

DELETE RESIDENT (STATE ONLY) OPTION ‘ H’

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: H

TECS CLIENT ID: _1234___

RESIDENT PAYMENT MONTH: ____ (MMYY / OPTIONS 'A','B','D','F')

N. D. DEPARTMENT OF HUMAN SERVICES

CHANGE BASIC CARE RESIDENT

TECS CLIENT ID: 00001137

RESIDENT NAME: CLAUS SANTA (LAST,FIRST,MI) SSN: 000-00-0000

BIRTHDATE: 12221908 AGE: 200

PERSONAL CARE RATE:$ 44.47 ROOM/BOARD RATE:$ 34.54 TOTAL RATE:$ 79.01

PROVIDER MEDICAID NUMBER: 30710____ CURRENT RATE:$ 79.01

FACILITY: NORTH POLE CARE CENTER EFFECTIVE DATE: 07012009

ADDRESS: 124 RAINDEER LANE

CITY: NORTH POLE STATE: ND ZIP: 58000

BCAP ELIGIBILITY START DATE: 051101 MEDICAID REDETERMINATION DUE DATE: 053111

FIRST FUNCTIONAL ASSESSMENT DATE: 051601

CURRENT FUNCTIONAL ASSESSMENT DATE: 091010

WORKER NAME: COUNTY ELF EW______WORKER COUNTY: 03

CLOSING EFFECTIVE DATE: ______

PRESS 'ENTER' TO CHANGE PRESS 'PF3' TO RETURN TO MENU

CHANGE FACILITY ADDRESS OPTION ‘ I’

N. D. DEPARTMENT OF HUMAN SERVICES

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: I

TECS CLIENT ID: ______

RESIDENT PAYMENT MONTH: ____ (MMYY / OPTIONS 'A','B','D','F')

Option I is only used by the State Office Medical Services Claims Division to change the a basic care facilities address. If Option I is selected and entered, you will receive the follow response.

NEXT SB6810 LIB=SS

SB6810 0520 NAT0963 Security violation during program execution (SB6818).

NOTICE MENU OPTION ‘N’

N. D. DEPARTMENT OF HUMAN SERVICES

BASIC CARE RESIDENT PAYMENT MENU

'A' ADD RESIDENT

'B' ADD MONTHLY RESIDENT PAYMENT

'C' CHANGE RESIDENT

'D' CHANGE MONTHLY RESIDENT PAYMENT

'E' INQUIRE ON RESIDENT

'F' INQUIRE ON MONTHLY RESIDENT PAYMENT

'G' DELETE RESIDENT (STATE ONLY)

'H' CHANGE WORKER COUNTY

'I' CHANGE FACILITY ADDRESS

'N' NOTICE MENU

'Z' TO EXIT

ENTER SELECTION: N

TECS CLIENT ID: ______

RESIDENT PAYMENT MONTH: ____ (MMYY / OPTIONS 'A','B','D','F')

‘N’ Notice Menu

BASIC CARE NOTICE MENU

'A' ADD NEW NOTICE

'C' CHANGE NOTICE (BEFORE PRINTING)

'D' DELETE NOTICE (BEFORE PRINTING)

'I' INQUIRE NOTICE

'Z' RETURN TO MAIN MENU

ENTER SELECTION: A

TECS ID: 556412

WORKER COUNTY: 18

PROVIDER NUMBER: 30778_ ( FOR OPTION 'A' ONLY )

ADD AN APPROVAL FOR BENEFITS NOTICE

FACILITY: TUFTE MANOR TECS-ID: 000000

3300 CHERRY STREET NAME: MOUSE MICKEY

GRAND FORKS ND 58201-

THE PURPOSE OF THIS NOTICE IS:

XAPPROVAL FOR BENEFITS _ CHANGE OF BENEFITS

_ DENIAL OF BENEFITS _ PENDING NOTIFICATION _ CASE CLOSING

EFFECTIVE DATE: 12012009

AMOUNT OF RECIPIENT RESPONSIBILITY: 155.37____ EFFECTIVE DATE: 12012009

INCREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: ___

DECREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: _

RSN: YOUR RECIPIENT RESPONSIBILITY IS $155.37. THIS IS THE AMOUNT YOU PAY TO TUFTE MANOR..

______

THANK YOU.______

______

______

WORKER NAME: DAISY D., EW I______ AGENCY: GRAND FORKS COUNTY SOC SV

ADDR: 151 S 4TH ST SUITE 201

POBOX 5196

GRAND FORKS ND 58206-5196

TELEPHONE NO: 701-787-8535

PF3 NOTICE MENU (DO NOT ADD NOTICE) PF10 ADD NOTICE

‘N’ Notice Menu

BASIC CARE NOTICE MENU SB6-820-01

'A' ADD NEW NOTICE

'C' CHANGE NOTICE (BEFORE PRINTING)

'D' DELETE NOTICE (BEFORE PRINTING)

'I' INQUIRE NOTICE

'Z' RETURN TO MAIN MENU

ENTER SELECTION: C

TECS ID: 556412

WORKER COUNTY:

PROVIDER NUMBER: FOR OPTION 'A' ONLY )

DEPARTMENT OF HUMAN SERVICES SB6-822-01

BASIC CARE NOTICE CHANGE

NOTICES FOR: 0000001234 CLAUS SANTA

SEQ TYPEDATE ENTERED DATE PRINTED WORKER NAME

1. DENIAL 01/10/2007 01/11/2007 COUNTY EW

2. DENIAL 01/19/2008 01/19/2008 COUNTY EW

3. APPROVAL01/23/2009 01/23/2009 COUNTY EW

4. CHANGE 01/24/2009 01/24/2009 COUNTY EW

5. CLOSE 05/27/2009 05/27/2009 COUNTY EW

6. APPROVAL 12/01/2009 PENDING COUNTY EW

6 ENTER THE LINE NUMBER OF THE NOTICE YOU WISH TO SELECT

LEAVE BLANK TO LIST ANY MORE NOTICES (IF ANY)

PRESS PF3 KEY TO VIEW PREVIOUS SCREEN

PRESS PF1 KEY TO RETURN TO NOTICE MENU

CHANGE APPROVAL FOR BENEFITS NOTICE

FACILITY: NORTH POLE CARE CENTER TECS-ID: 000000

1234 RAINDEER LANE NAME: SANTA CLAUSE

BISMARCK ND 58000

THE PURPOSE OF THIS NOTICE IS:

XAPPROVAL FOR BENEFITS _ CHANGE OF BENEFITS

_ DENIAL OF BENEFITS _ PENDING NOTIFICATION _ CASE CLOSING

EFFECTIVE DATE: 12012009

AMOUNT OF RECIPIENT RESPONSIBILITY: 200.37 EFFECTIVE DATE: 12012009

INCREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: ___

DECREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: _

RSN: YOUR RECIPIENT RESPONSIBILITY IS $200.37 THIS IS THE AMOUNT YOU PAY TO NORTH POLE CARE CENTER..

______

THANK YOU.______

WORKER NAME: DAISY D., EW I______AGENCY: GRAND FORKS COUNTY SOC SV

ADDR: 1234 RAINDEER LANE

PO BOX 1234

BISMARCK ND 58000

TELEPHONE NO: 701-

PF3 NOTICE MENU (DO NOT ADD NOTICE) PF10 ADD NOTICE

‘N’ Notice Menu

BASIC CARE NOTICE MENU

'A' ADD NEW NOTICE

'C' CHANGE NOTICE (BEFORE PRINTING)

'D' DELETE NOTICE (BEFORE PRINTING)

'I' INQUIRE NOTICE

'Z' RETURN TO MAIN MENU

ENTER SELECTION: D

TECS ID: 556412

WORKER COUNTY:

PROVIDER NUMBER: FOR OPTION 'A' ONLY )

DEPARTMENT OF HUMAN SERVICES SB6-822-01

BASIC CARE NOTICE CHANGE

NOTICES FOR: 0000001234 CLAUS SANTA

SEQ TYPEDATE ENTERED DATE PRINTED WORKER NAME

1. DENIAL 01/10/2007 01/11/2007 COUNTY EW

2. DENIAL 01/19/2008 01/19/2008 COUNTY EW

3. APPROVAL01/23/2009 01/23/2009 COUNTY EW

4. CHANGE 01/24/2009 01/24/2009 COUNTY EW

5. CLOSE 05/27/2009 05/27/2009 COUNTY EW

6. APPROVAL 12/01/2009 PENDING COUNTY EW

6 ENTER THE LINE NUMBER OF THE NOTICE YOU WISH TO SELECT

LEAVE BLANK TO LIST ANY MORE NOTICES (IF ANY)

PRESS PF3 KEY TO VIEW PREVIOUS SCREEN

PRESS PF1 KEY TO RETURN TO NOTICE MENU

DELETE A NOTICE

FACILITY: NORTH POLE CARE CENTER TECS-ID: 000000 SB6-821-01

1234 RAINDEER LANE NAME: SANTA CLAUSE

BISMARCK ND 58000

THE PURPOSE OF THIS NOTICE IS:

XAPPROVAL FOR BENEFITS _ CHANGE OF BENEFITS

_ DENIAL OF BENEFITS _ PENDING NOTIFICATION _ CASE CLOSING

EFFECTIVE DATE: 12012009

AMOUNT OF RECIPIENT RESPONSIBILITY: 200.37 EFFECTIVE DATE: 12012009

INCREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: ___

DECREASE IN RECIPIENT RESPONSIBILITY: ______EFFECTIVE DATE: _

RSN: YOUR RECIPIENT RESPONSIBILITY IS $200.37 THIS IS THE AMOUNT YOU PAY TO NORTH POLE CARE CENTER..

______

THANK YOU.______

WORKER NAME: DAISY D., EW I______AGENCY: BURLEIGH COUNTY SOC SV

ADDR: 1234 RAINDEER LANE

BISMARCK ND 58000

TELEPHONE NO: 701-

PF3 NOTICE MENU (DO NOT ADD NOTICE) PF10 DELETE NOTICE

‘N’ Notice Menu

BASIC CARE NOTICE MENU SB6-820-01

'A' ADD NEW NOTICE

'C' CHANGE NOTICE (BEFORE PRINTING)

'D' DELETE NOTICE (BEFORE PRINTING)

'I' INQUIRE NOTICE

'Z' RETURN TO MAIN MENU

ENTER SELECTION: I

TECS ID: 556412

WORKER COUNTY:

PROVIDER NUMBER: FOR OPTION 'A' ONLY )

FACILITY: NORTH POLE CARE CENTER TECS-ID: 1234 SB6-822-02

1234 RAINDEER LANE NAME: CLAUS SANTA

NORTH POLE ND 58000

THE PURPOSE OF THIS NOTICE IS:

APPROVAL FOR BENEFITS X CHANGE OF BENEFITS

DENIAL OF BENEFITS PENDING NOTIFICATION CASE CLOSING

EFFECTIVE DATE: 2/1/2004 DATE PRINTED: 1/21/2004

AMOUNT OF RECIPIENT RESPONSIBILITY: 467.90 EFFECTIVE DATE: 02/01/2004

INCREASE IN RECIPIENT RESPONSIBILITY: EFFECTIVE DATE:

DECREASE IN RECIPIENT RESPONSIBILITY: EFFECTIVE DATE:

RSN: CHANGE IN RECIPIENT RESPONSIBILITY TO $467.90 BECAUSE OF AN INCREASE IN CO-PYAMENTS.

WORKER NAME: COUNTY EW. AGENCY: BURLEIGH COUNTY SOC SERV

ADDR: 1234 RAINDEER LANE

BISMARCK ND 58000

TELEPHONE NO: 701-

Additional notes:

• If there are no monthly changes, the worker does not need to authorize the case through because it will automatically roll over and no notice will generate.

• The resident payment system can only send out notification to the recipient and the facility. The system does not have the ability to also send a notice to a guardian.

• The system does not track disqualification information because of a transfer of income or assets. This must be documented in the case file and in the denial notice sent to the individual.

• To deny an application for assistance, enter client information by selecting Option A. Send a denial notice referencing the reasons for the denial.