Form DHS-390: Adult Services Application

If you need help to complete this application, indicate what kind of help you need: Bilingual Interpreter, Sign-language interpreter for the deaf, or Other (specify).

In SECTION 2 - CLIENT INFORMATION, enter in Box 8 the Full Name of Person Needing or Requesting Services and in Box 9 the Date of Birth (MM-DD-YYYY).

Enter the Medicaid/Recipient ID in Box 10.

Enter in Box 11 the Street Address, City, State and Zip Code.

Enter in Box 12 the Phone Number, in Box 13 the TTY Number (Teletype for the deaf) and in Box 14 the Email Address.

SECTION 3 - DEPARTMENT PROGRAMS, Home Help: Services to help pay for someone to assist with personal care and housekeeping.

Adult Community Placement: Services for adults who can no longer remain in their own homes. Includes help finding an adult foster care home or home for the aged and services for people living in these settings.

Other Services: Non-payment services to help adults stay safe in their own homes. Services may include information and referral to other community resources.

Your status as a recipient: Medicaid (MA) recipient; Medicaid application pending; Supplemental Security Income (SSI) recipient; MI Choice Waiver recipient; PACE recipient; MI Health Link recipient; Community Mental Health (CMH) recipient; Food Assistance recipient; Family Independence Program (FIP) recipient; State Disability Assistance (SDA) recipient; Veteran Affairs recipient.

Living Arrangement: Select all boxes that apply to you and answer related questions.

Alone. With spouse (if married answer the spouse questions): Is spouse disabled? Yes or No. Is spouse working? Yes or No. Enter the Full name of spouse.

With children under age 18. How many?

With others (relatives and non-relatives) How many?

Live in adult foster care facility, home for the aged.

Is client in a hospital or nursing home? Yes or No.

Do you have a guardian? Yes or No. Enter the Name of guardian.

Is a caregiver/provider already identified? Yes or No.

Read the following statement, sign, and date the application. I wish to apply for one of the adult services programs. I certify that the information I have given is correct. By signing, I acknowledge that I have read and agree to the rights, responsibilities, and important things to know described in Section 5 of this application.

Sign on the Client Signature line and enter the Date.

Application: You have the right to apply for adult services programs at any time.

Your application must be approved or denied within 45 days from the day your referral is received by MDHHS. You must report any changes regarding your case to your adult services worker within ten business days of the change.

Complete the CLIENT INFORMATION, SECTION 3, and SECTION 4, and sign and date the second page. Return the first and second pages of this Adult Services Application using the enclosed business reply envelope.