Iowa Form 470 3361 PDF Details

The Iowa Department of Human Services has implemented a vital initiative designed to support children in DHS custody with severe disabilities, aiming to connect them with the benefits available through the Supplemental Security Income (SSI) program. This initiative, facilitated by a partnership with MAXIMUS, focuses on the precise identification and application process for eligible children, ensuring they gain access to crucial financial support. The key document at the center of this process is the Iowa 470 3361 form, titled "SSI ADVOCACY PROJECT REFERRAL," which gathers essential information about the child, including name, date of birth, social security number, and details about their current placement and care situation. To qualify for referral, a child must be in the custody of the DHS or JCS and have a diagnosed mental or physical impairment. The form inquires about specific indicators of eligibility, such as receipt of psychiatric services, special education due to severe learning issues, or intensive medical treatment for physical illnesses, among others. It aims to streamline the referral process, making it easier for caretakers and officials to connect children with the benefits they need. Communication with MAXIMUS, including questions regarding referrals and updates on placement changes, is facilitated through provided contact information, ensuring a clear channel for assistance throughout the application process.

QuestionAnswer
Form NameIowa Form 470 3361
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names470 3361 maximus ssi form

Form Preview Example

Iowa Department of Human Services

SSI ADVOCACY PROJECT REFERRAL

The Iowa Department of Human Services has selected MAXIMUS to assist in the identification of children in DHS custody who have severe disabilities and may be eligible for Supplemental Security Income benefits. MAXIMUS will file the application for benefits for children who appear to be eligible. If you have questions about referrals, please contact MAXIMUS at 1-800-778-1406.

Child’s Name

 

Date of Birth

Social Security Number

 

 

 

 

 

Foster Care Parents/Facility

 

 

Telephone

 

 

 

(

)

 

 

 

 

 

 

 

Street

 

City

State

 

Zip Code

 

 

 

 

 

 

Date of Placement

Is there a court order placing the child in DHS or JCS custody?

Does child have a diagnosed mental/physical impairment?

Yes

Yes

No

No

If “no” for either of these questions, do not proceed with referral.

Following are some indicators that a child may qualify for the SSI program (check all that apply):

Child has received (within last six months) or is receiving psychiatric hospital services due to diagnosed mental impairment other than substance abuse

Child was recently discharged from or is currently in a residential facility due to diagnosed mental impairment other than substance abuse

Child receives special education services to address severe learning problems

Child receives intensive outpatient counseling and/or therapy (must check one other indicator in addition to this one)

Child has moderate to severe mental retardation (IQ 70 or less)

Child has severe developmental delays (functioning one-half or less of chronological age)

Child receives intensive medical services and/or treatment for a physical illness

Infant (less than six months old) was born at a very low birth weight (1200 grams or less)

Is the child receiving any benefits based on a deceased, disabled or retired parent’s account?

Yes

No

Referred By

County

Telephone

( )

Date

DHS

JCS

Send referral to: MAXIMUS

Fax: 515-284-8854 E-mail: iowassi@maximus.com

PLEASE REPORT PLACEMENT CHANGES TO MAXIMUS

470-3361 (Rev. 9/05)

How to Edit Iowa Form 470 3361 Online for Free

You can prepare Iowa Form 470 3361 effectively in our online tool for PDF editing. The editor is continually upgraded by our staff, acquiring powerful functions and turning out to be even more convenient. Getting underway is easy! All you need to do is adhere to the next simple steps directly below:

Step 1: Press the orange "Get Form" button above. It will open up our pdf editor so that you could begin filling in your form.

Step 2: After you launch the file editor, you will notice the form prepared to be filled in. Besides filling in various blank fields, you can also do many other things with the file, specifically putting on custom textual content, changing the initial text, inserting images, affixing your signature to the PDF, and a lot more.

It's an easy task to finish the document using this detailed guide! Here is what you want to do:

1. When completing the Iowa Form 470 3361, make certain to complete all needed fields in the associated part. This will help hasten the work, enabling your information to be handled without delay and appropriately.

Writing section 1 in Iowa Form 470 3361

Step 3: Immediately after looking through the fields and details, press "Done" and you are all set! Try a free trial subscription with us and obtain immediate access to Iowa Form 470 3361 - which you'll be able to then work with as you wish inside your personal account page. FormsPal ensures your data confidentiality by having a secure system that never records or distributes any kind of sensitive information involved. Be confident knowing your paperwork are kept safe whenever you use our editor!

Iowa Form 470 3361 isn’t the one you’re looking for?

Related Documents