473 NAC 1-005
The following forms are used by local offices to administer the Social Services Program for adults. Instructions for these forms are contained in the appendix at the end of this title:
Form Appendix
Number Form Title Reference
DPW-1 Request for Assistance and/or Services 473-000-10
DPW-19 Client Referral 473-000-11
DPW-46 Authorization for Investigation 473-000-12
DPW-100 De-Institutionalization Referral 473-000-13
DSS-2A Social Service Exception 473-000-21
DSS-3A Social Services Application 473-000-22
DSS-3B Physician's Disability Determination 473-000-23
DSS-4 Case Information Summary 473-000-25
DSS-4A Social Services Provider Authorization 473-000-26
DSS-4C Service Provider Notification 473-000-27
DSS-5B Social Services Billing Document 473-000-28
DSS-6 Client's Notice of Action 473-000-29
DSS-8 Agency Service Provider Agreement 473-000-30
DSS-8A Agency Service Provider Agreement Amendment 473-000-31
DSS-9 Individual Service Provider Agreement 473-000-32
DSS-10 Social Service Provider Identification 473-000-33
DSS-60 Adult Abuse/Neglect Report 473-000-39
DSS-0151 Chore Service Provider Check List 473-000-50
DSS-0251 Adult Day Service Provider Check List 473-000-60
DSS-0750 Adult Family Home Application 473-000-70
DSS-0751 Adult Family Home Sponsor Medical Report 473-000-71
DSS-0752 Adult Family Home Agreement 473-000-72
DSS-0753 Adult Family Home Inspection Referral 473-000-73
DSS-0754 Evaluation of Adult Family Home 473-000-74
DSS-0755 Adult Family Home Certificate 473-000-75
DSS-0926 Request for State Health Department
Investigation 473-000-80
DSS-1052 Home Delivered or Congregate Meals Provider
Check List 473-000-90
DSS-1053 Weekly Menu Plan 473-000-91
DSS-1054 Approved Meals Service Vendor Meals
Specification List 473-000-92
DSS-1151 Homemaker Provider Check List 473-000-100
DSS-1153 Homemaker Weekly Time Sheet 473-000-101
DSS-1154 Homemaker Service Task List 473-000-102
DSS-1650 Abuse/Neglect Hotline Intake Form 473-000-120
DSS-1851 Transportation Review Guide and Check List 473-000-130
IRS-2678 Employer Appointment of Agent 473-000-140
PDS-100 Client Identification Data 473-000-150
SDX-260 SDX Master File by County 473-000-160
SS-1610 Social Security -- Public Assistance Agency Information Request and Report 473-000-170