Form 04Ic012E PDF Details

Facilitating the safe and effective placement of children across state lines involves meticulous planning and coordination, particularly when it comes to addressing their financial and medical needs. The 04IC012E form, developed by the Oklahoma Department of Human Services, is a critical tool in this process, specifically designed to ensure that children placed in another state under the Interstate Compact on the Placement of Children (ICPC) have their essential needs met. This form is completed by the Child Welfare county worker for every child, detailing a comprehensive plan for the child's shelter, food, clothing, maintenance needs, and medical coverage in the receiving state. It delineates different scenarios including placement with relatives, foster care, with parents, or for adoption, and outlines how the financial aspects and medical coverage will be handled. Whether a child is eligible for Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), foster care payments, adoption subsidies, or Medicaid, this document ensures that all parties involved—the sending and receiving states, the caretakers, and most importantly, the child—are aware of and have agreed upon the financial and medical roadmap ahead of the placement. By requiring a detailed plan before the placement request is made, it underscores the collaborative effort between states to look after the welfare of children under the ICPC, underscoring a nationwide commitment to child safety and well-being.

QuestionAnswer
Form NameForm 04Ic012E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names04IC012E lifeline and okdhs form

Form Preview Example

*04IC012E-001*

OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Interstate Compact on the Placement of Children

Financial/Medical Plan

The Child Welfare (CW) county of jurisdiction worker completes this form for each child.

Child's name

Date of birth

Resource name

Financial plan. Description of how the child's shelter, food, clothing, and related maintenance needs will be met in the receiving state. Before submitting an Interstate Compact on the Placement of Children request, the CW worker contacts the potential placement provider to determine how the child's financial needs will be met.

Check only one.

1.Form 04IC002E (ICPC-100-A), Interstate Compact on the Placement of Children Request, is used to request a relative home study. 1 The child will be placed with a relative in another state.

• Relative resource agrees to meet the financial needs of the child.

•Relative resource will apply for Temporary Assistance for Needy Families (TANF) child-only grant/benefits in the receiving state on behalf of the child.

NOTE: TANF child-only grant/benefits are not available in all states.

•Child is eligible for Supplemental Security Income (SSI). Resource will be

made payee for benefits.

2.Form 04IC002E is used to request a foster home study. The child will be placed with a relative or non-relative who is licensed or certified as a foster home in another state.

•Resource is entitled to receive foster care payments from Oklahoma.

Oklahoma will pay foster care at receiving state's rate.

• Child is SSI-eligible. Resource will be made payee for benefits.

3.Form 04IC002E is used to request a parent home study. The child will be placed with his or her parent(s) in another state. The parent(s) is expected to:

• support this child.

• apply for welfare assistance in the receiving state if unable to support child.

1ICPC relative home study requests are non-paid placements and are not entitled to foster care payment.

Revised 11-1-2008

04IC012E (ICPC-104)

Page 1 of 2

04IC012E (ICPC-104)

FINANCIAL/MEDICAL PLAN

4.Form 04IC002E is used to request an adoptive home study. The child will be placed with relatives, or licensed foster caregivers, or others, in another state.

• Resource agrees to meet the financial needs of the child.

•Child is eligible for Supplemental Security Income (SSI). Resource will be

made payee for benefits.

•Resource is entitled to receive foster care payments from Oklahoma. Oklahoma

will pay foster care at receiving state's rate until the adoption is finalized.

•Child is eligible for adoption subsidy payments; however, any subsidy payment amounts will be negotiated with the prospective adoptive family

after approval as a resource.

Medical plan. Description of how the child's medical coverage needs will be met in the receiving state.

Check only one.

•Child is Title IV-E eligible. The receiving state will arrange for SoonerCare (Medicaid) coverage based on Title IV-E eligibility. The CW worker preparing this form verifies IV-E eligibility for the child by checking IV-E status on the KIDS IV-E Eligibility screen. The CW worker: prints Form 04KI002E (CWS-KIDS-4), Eligibility Determination; completes IV-E eligibility section; and attaches Form 04KI002E to this form. If IV-E status is pending, the CW worker contacts the

custody specialist to determine whether the child's IV-E eligibility will be established prior to making the ICPC placement.

•Child is eligible for SoonerCare (Medicaid) in the receiving state under TANF

child-only grant/benefits.

•Child is not Title IV-E eligible. The child will reside in substitute care or with a relative. Oklahoma will issue a medical card if the resource is unable to receive medical coverage for the child in the receiving state. The placement provider is responsible for locating resources that contract with Oklahoma Health Care

Authority for medical services.

• Child is SoonerCare (Medicaid) eligible as a recipient of SSI.

•Placement resource agrees to provide for and meet the medical needs of the

child without financial assistance from Oklahoma.

•Placement is with a parent(s). The parent(s) is financially responsible for

meeting the medical needs of the child.

Oklahoma remains responsible for the financial and medical needs of a child who is under Oklahoma court jurisdiction and in the custody of OKDHS. In the event of a placement disruption, Oklahoma is financially responsible for the return of the child as long as Oklahoma retains jurisdiction.

CW worker signature

County

Date

Original and two copies

–

Children and Family Services Division ICPC Unit

One copy

–

Local case record

 

 

Page 2 of 2

Revised 11-1-2008

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1. It is crucial to complete the Form 04Ic012E correctly, hence be careful while filling in the segments containing these specific blank fields:

The best ways to fill out Form 04Ic012E part 1

2. Once your current task is complete, take the next step – fill out all of these fields - Resource is entitled to receive, Oklahoma will pay foster care at, Child is SSIeligible Resource, Form ICE is used to request a, with his or her parents in another, support this child, apply for welfare assistance in, ICPC relative home study requests, Revised, ICE ICPC, and Page of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

The best ways to fill out Form 04Ic012E step 2

A lot of people frequently get some things wrong when completing with his or her parents in another in this part. Ensure you read twice whatever you enter here.

3. Within this step, take a look at placed with relatives or licensed, Resource agrees to meet the, made payee for benefits, Resource is entitled to receive, will pay foster care at receiving, payment amounts will be negotiated, Medical plan Description of how, Check only one, Child is Title IVE eligible The, and Child is eligible for SoonerCare. Each one of these have to be filled out with highest attention to detail.

Completing section 3 in Form 04Ic012E

4. The next section needs your details in the subsequent places: Child is not Title IVE eligible, Child is SoonerCare Medicaid, child without financial assistance, Placement is with a parents The, meeting the medical needs of the, Oklahoma remains responsible for, CW worker signature, County, Date, Original and two copies One copy, and Children and Family Services. Just be sure you enter all of the requested details to move further.

Form 04Ic012E conclusion process detailed (part 4)

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