Form #

Form Title

PAF Reference

ASD-10

Address Information Request

1-1

ASD-17

Question Referral Form

1-2

ASD-19

Client Referral Form

1-3

ASD-46

Authorization for Investigation

1-4

ASD-59

Insurance Information System

1-6

ASD-60

Health Insurance Verification Form

1-7

ASD-63

Referral for Investigation

1-8

CSE-10

Notice of Non-Cooperation

3-1

CSE-11

Support Repayment Agreement

3-2

CSE-11D

Voluntary Agreement to Reduce Benefits

3-3

CSE-12

Acknowledgement of Paternity

3-4

CSE-30A

Acknowledgement of Assignment of Child/Spousal Support Rights

3-8

CSE-31

Acknowledgement of Assignment of Child Support Rights

3-6

DA-3M

Medical Budget and Record

4-1

DA-3MXL

Medical Assistance Budget and Record

4-2

DA-4M

Medical Assistance Budget

4-3

DA-6

Notice and Petition for Fair Hearing

4-4

DA-100

Application for Assistance

4-5

DA-100A

Supplement to the Application for Assistance

4-6

DA-100B

Supplement to the Application for Assistance, Food Stamp Filing Page

4-7

DA-100C

Application Checklist

4-8

DM-5

Physician's Confidential Report

4-10

DM-5LTC

Long Term Care Evaluation

4-12

DM-5LTC-LTC

Long Term Care Evaluation for Intermediate Care Facilities for the Mentally Retarded

4-13

DM-5R

Disability Report

4-14

DM-12D

Social Study

4-15

DSS-5

Authorization and Billing Document

4-16

DSS-5B

Social Services Billing Document

4-17

DSS-68

Presumptive Eligibility Budget Sheet

4-20

DSS-160

Share of Cost

4-29

DSS-500

Application for Assistance

4-35

EPSDT-3

EPSDT Follow-Up

5-1

FA-10

Report of Vendor Home Repairs

6-1

FA-62

Maintenance Assistance Cancellation/ Refund Transmittal

6-3

G-845

Document Verification Request

7-1

HCFA-1450/UB-82

8-1

I-94

Arrival Departure Record

9-1

I-151

Alien Registration Receipt Card

9-2

I-181

Memorandum of Creation of a Record of Lawful Permanent Residence

9-3

I-551

Alien Registration Receipt Card

9-4

IM-1

Agreement to Sell Real Property and Repay Assistance

9-5

IM-2

IM Referral to Vocational Rehabilitation

9-6

IM-5

Notice to the Child Support Enforcement Unit of a Good Cause Claim

9-7

IM-8

Notice of Finding

9-12

IM-17E

Interim Assistance Reimbursement Authorization - Eligibility

9-17

IM-17P

Interim Assistance Reimbursement Authorization - Post Eligibility

9-18

IM-20

Educational Benefits and Housing Verification

9-23

IM-22

Certificate Request

9-26

IM-24

Notice of Excess Income Obligation

9-27

IM-25

Budget

9-25

IM-25I

Initial Eligibility Budget

9-30

IM-25C

Continuing Eligibility Budget

9-31

IM-28

Notice of Transfer

9-33

IM-50

Retroactive Payment Worksheet

9-37

IM-60

Medical Assistance Notice of Requirement to Cooperate and Right to Claim Good Cause

9-47

IM-61

Overpayment/Recoupment Calculations

9-48

IM-64

Request for Voluntary Repayment

9-50

IM-68

Referral for Social Security Number Application

9-59

IM-73

Assessment of Resources

9-53

IM-74

Designation of Resources

9-56

IM-QRF

Quarterly Report Form

9-54, 9-55

MC-4

Long Term Care Turnaround Billing Document

10-2

MC-5

EPSDT Screening Report

10-1

MC-9-AD

Prior Authorization for Assisted Living Waiver Services

10-4

MC-9-NF

Prior Authorization for Nursing Facility Care

10-2

MC-10

Prior Authorization Document Adjustment

10-3

MC-12

Excess Income Obligation Claims

10-4

MC-13

Dentist Pretreatment Plan and Service Statement

10-5

PDS-2

Reconciliation of Supplemental Medical Insurance Benefits (SMIB)

11-1

PDS-22

Bendix Discrepancy Report Form

11-2

PDS-38

Nebraska Medicaid Card

11-3

PDS-113

Adjustment Request for Client Medical Eligibility Record

11-4

QC-1

Quality Control Review Findings

12-1

SE-1

Self-Employment and Farm Income Worksheet

13-1

SS-5

Application for a Social Security Number

13-2

SSA-491TC

Automated Third Party Query

13-3

SSA-1610

Social Security Public Assistance Agency Information Request and Report

13-4

SSA-2853

Message from Social Security

13-5

SSA-4681

Case Report on Claim of Good Cause for Refusing to Cooperate in Establishing Paternity and Securing Child Support

13-6

SSA-5028

Receipt for Application for a Social Security Number

13-7

SSA-7028

Notification of SSN to Third Party

13-7

TMA/TCC1

Notice of Eligibility for Transitional Medical/Child Care Assistance

14-2

TMA/TCC2

Notice of Additional Transitional Medicaid and Child Care

14-3

TMA/TCC3

Notice of Additional Transitional Medicaid and Child Care

14-4

TMA/TCC4

Notice of Additional Transitional Medicaid and Child Care

14-5

WP-1

Job Support Referral and Communication Form

15-1

WP-2

Monthly Job Support Report

15-2

WP-3

ADC/Job Support Status Change Form

15-3

WP-4A

Job Support Appraisal and Employability Plan

15-4

WP-4B

Employability Plan

15-5

WP-5

Notice of Failure to Cooperate

15-6

WP-6

Work Experience Referral for Worksite Placement

15-7

511-UP

Job Service Application

16-1