TN 58 (06-24)

SI 00520.930 Exhibits of Prerelease Agreements, Referrals, and Forms

 

EXHIBIT 1 - Model Prerelease Agreement between SSA and non-BOP Institution

EXHIBIT 2 - Model Prerelease Referral

EXHIBIT 3 – Modified Form SSA-3288 (Consent for Release of Information) for use in BOP prerelease claims

 

EXHIBIT 1 - Model Prerelease Agreement between SSA and non-BOP institution

    

The facility:

1. 1. 

   Identifies patients or residents scheduled or considered for discharge from the facility within 30 days after the notice of the SSI eligibility decision or for whom eligibility for Social Security benefits has been established;

2. 2. 

   Provides the local SSA office with the names of potential prerelease applicants, as well as their social security number, date of birth, and anticipated discharge date;

3. 3. 

   Refers only those individuals who appear to meet the SSI income and resource criteria or those potentially entitled to Social Security benefits;

4. 4. 

   Provides nonmedical information for development of whether the individual meets all eligibility requirements;

5. 5. 

   Provides current medical evidence consistent with SSA guidelines and recommendations of the Disability Determination Services (DDS) and a statement about the individual’s ability to handle funds;

6. 6. 

   Notifies the local SSA office of any changes that could result in discharge over 30 days after the notice of the eligibility decision;

7. 7. 

   Notifies the local SSA office as soon as the facility discharges the patient or resident; and

8. 8. 

   Designates a liaison to:

   • •

     handle all referrals;

   • •

     notify the local SSA office of any pertinent changes; and

   • •

     respond to any local SSA office inquiries.

    

The local SSA office:

1. 1. 

   Provides guidelines for the kinds of information requested from the facility;

2. 2. 

   Reviews with facility personnel the prerelease procedures at least once a year and whenever procedures or the facility liaison changes;

3. 3. 

   Designates a local SSA office liaison to:

   • •

     assist the facility’s staff in initiating and completing prerelease applications; and

   • •

     respond to the facility’s inquiries.

4. 4. 

   Processes all prerelease claims in an expeditious and timely manner;

5. 5. 

   Identifies prerelease cases for the DDS to ensure prompt handling; and

6. 6. 

   With the individual’s permission, notifies the facility of the eligibility decision.

  

EXHIBIT 2 - Model Prerelease Referral from Facility to SSA Office  

 

EXHIBIT 3 - Modified Form SSA-3288 (Consent for Release of Information) for use in BOP prerelease claims