GEORGIA DEPARTMENT OF HUMAN RESOURCES
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC)
FINANCIAL AND MEDICAL PLAN
Date___________________________
Complete one form for each child. Complete one additional form for the same child for each separate resource being studied.
Child's Name_______________________________ Child's DOB______________________________
Name of County____________________________ Name of Resource__________________________
FINANCIAL PLAN (Check all that apply}
q We will provide
q Foster care payment
q Enhanced Relative Rate
q Adoption Assistance
q This is a return to parent under reunification. The parent will provide financially for the child.
q The relative resource will apply for TANF Child-Only Grant in the receiving state on behalf of the child. Note: Child-Only Grants are not available in all states.
q Child is SSI eligible. Resource will be made payee for benefits.
MEDICAL PLAN (Check all that apply)
q The receiving state will arrange for Medicaid coverage based on the provisions of the federal COBRA legislation (Title IV-E). Include IV-E documentation.
q The child is not IV-E eligible. The sending agency will provide a medical card or reimbursement for . the child's medical expenditures incurred with prior approval. Include billing and medical emergency
instructions.
q This is a return to parent under reunification. The parent will provide medically for the child.
q Other (Explain)
__________________________________________________________________________________
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The Georgia Department of Human Resources/Department of Family and Children Services remains ultimately responsible for the support of the child and will retain jurisdiction over the child as mandated by the ICPC (Article V). It shall continue to have financial responsibility for the support and maintenance of the child during the period of placement. In the event of a placement disruption and return of the child, the Department will pay the transportation cost and expects the full cooperation of the receiving state to accomplish this return. This plan will remain in effect until proper legal discharge, consistent with the provisions of the Interstate Compact on the Placement of Children.
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Signature of Referring Worker/Supervisor
FC_99 Financial and Medical Plan (Rev. 11-06)