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1.
Model Informational Notice to Institutions
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2.
Model Institutional Agreement Form
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3.
Model Institutional Notice Form—No Medicaid Involvement
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4.
Model Institutional Notice Form—Medicaid Involved
EXHIBIT 1 - MODEL INFORMATIONAL NOTICE TO INSTITUTIONS
SOCIAL SECURITY ADMINISTRATION
SUPPLEMENTAL SECURITY INCOME
IMPORTANT INFORMATION
Date:
Name of Administrator
Name of Institution
Street Address
City/State /Zip Code
Dear :
We need your help to see that certain supplemental security income (SSI) recipients
benefit from a special provision affecting their eligibility and payments for SSI.
Under Section 1611(e)(1)(E) of the Social Security Act, we can pay the full Federal
benefit rate to certain institutionalized individuals. These individuals would be
ineligible for SSI or their Federal payments would be no more than $30 a month. Under
the provision, we can pay them for the first two full months of institutionalization.
This allows individuals to continue to meet expenses outside the institution, such
as maintaining their homes.
For us to make these specials payments, you must agree that your institution will
not require the individual to pay any part of the SSI payment to the institution.
Medicaid law also requires that you disregard these payments when determining the
amount the individual would be expected to pay towards the cost of care.
We would appreciate your agreeing to the conditions outlined above. If you do agree,
please sign (or have someone on your behalf sign) the enclosed agreement form. Please
return the original form in the enclosed envelop.
If you agree, we will send you the name(s) and Social Security number(s) of any resident(s)
of your institution who qualify under this provision. We will also provide the months
for which the agreement applies.
If you have any questions, please call our office and ask for (name of contact
person) . Their telephone number is (xxx) xxx-xxxx.
Sincerely,
Manager's name
Manager's Title
Enclosure (2)
EXHIBIT 2 - MODEL INSTITUTIONAL AGREEMENT FORM
SOCIAL SECURITY ADMINISTRATION
SUPPLEMENTAL SECURITY INCOME
IMPORTANT INFORMATION
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TO:
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Field Office Manager
Social Security Administration
Street Address
City/State/Code
Acting on behalf of (name of institution(s)), I agree that any individuals identified
as potential recipients of supplemental security income (SSI) under section 1611(e)(1)(E)
of the Social Security Act will not be required to pay any part of the Section 1611(e)(1)(E)
SSI payment to this institution.
I understand that the Social Security Administration (SSA) will send us the name(s)
and Social Security number(s) of the resident(s) of our institution(s) who qualify
under this provision. SSA will also provide the month(s) for which the agreement applies.
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Signature of Authorized Person from Institution |
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Title |
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Date |
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Signature of Authorized Person from SSA |
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Title |
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Date |
EXHIBIT 3 - MODEL INSTITUTIONAL NOTICE FORM - NO MEDICAID INVOLVEMENT
SOCIAL SECURITY ADMINISTRATION
SUPPLEMENTAL SECURITY INCOME
IMPORTANT INFORMATION
Name of Authorized Person
Name of Institution
Street Address
City/State/Zip code
The individual(s) listed below, who is a resident of your facility, is eligible for
supplemental security income (SSI) payments under section 1611(e)(1)(E) of the Social
Security Act. For the months listed below the individual(s) will not be required to
pay any portion of the SSI payment to your institution. This is based on the agreement
dated between the Social Security Administration and your institution.
Recipient's Name |
Recipient's Social Security Number |
Months for which Special Payments Apply |
If you have any questions, please call our office and ask for (name of contact
person) . Their telphone number is (xxx) xxx-xxxx.
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Manager's Name |
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Manager's Title |
EXHIBIT 4—MODEL INSTITUTIONAL NOTICE FORM — MEDICAID INVOLVED
SOCIAL SECURITY ADMINISTRATION
SUPPLEMENTAL SECURITY INCOME
IMPORTANT INFORMATION
Name of Authorized Person
Name of Institution
Street Address
City/State/Zip code
The individual(s) listed below, who is a resident of your facility, is eligible for
supplemental security income (SSI) payments under section 1611(e)(1)(E) of the Social
Security Act. For the months listed below the individual(s) will not be required to
pay any portion of the SSI payment to your institution.
Recipient's Name |
Recipient's Social Security Number |
Months for which Special Payments Apply |
If you have any questions, please call our office and ask for (name of contact
person) . Their telphone number is (xxx) xxx-xxxx.
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Manager's Name |
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Manager's Title |