form19 32 Brown MHCAP APPLICATION Name(Required) First Last Date Of Birth(Required) MM slash DD slash YYYY PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Marital Status Never Married Single Legally Seperated Divorced Widowed Hispanic Heritage Yes No Race American Indian/Alaskan Native Asian Black or African American Pacific Island/Native Hawaiian White Social Security NumberOther Household MembersName First Last Date Of Birth MM slash DD slash YYYY Relationship Name First Last Date Of Birth MM slash DD slash YYYY Relationship Name First Last Date Of Birth MM slash DD slash YYYY Relationship Name First Last Date Of Birth MM slash DD slash YYYY Relationship Financial InformationDiversionary Work Program (DWP / MN Family Investment Project (MFIP) Yes No Are you an adult caretaker of children who receive DWP/MFIP Yes No Do you receive Supplemental Security Income (SSI)? Yes No If Yes Aged Blind Disabled Do you receive Minnesota Supplemental Aide (MSA)? Yes No Do you receive Medical Assistance (MA)? Yes No Complete the information below for all family members (including yourself) who are age 14 or older. Please provide proof of all income for the past three months (or) include a copy of your most recent Income Tax Statement.Complete the information below for all family members (including yourself) who are age 14 or older. Use + to add people. Kind of Income (Monthly Gross Amount)Wage or SalaryWage or SalaryNET Income from Self EmploymentNET Farm IncomeSocial SecuritySocial SecurityDividends – Interest – Rentals – RoyaltiesGeneral AssistancePensions and AnnuitiesUnemployment CompensationWorkers CompensationAlimonyChild SupportChild SupportVeterans Pensions Add RemoveTotal Monthly Household IncomeFamily SizeTotal Monthly IncomeMonthly Fee:Do you have private insurance? Yes No Insurance Waiver Appeal: Please state reason the waiver should be granted on back of form: Insurance Waiver Appeal: You may request that your application for the Mental Health Client Assistance Program be considered if you feel there are special and unusual circumstances. Special or unusual circumstances could include mental health services not being a covered service with your current insurance or the inability to pay large deductibles or copays. The appeal must be in writing stating the reasons the waiver should be granted and desire for review. The Mental Health Supervisor, in consultation with the Director, will review requests and determine if waiver will be granted. If the waiver is granted, the Mental Health Client Assistance Program fee schedule will be utilized to assess any potential fees.My signature below authorizes the exchange of information between Southern Minnesota Behavioral Health and Watonwan County Human Services to include: • All information provided on this application • Copies of proof of income reported. • Diagnostic information including mental health professional recommendations • Service dates and services provided I understand this information is needed in order to process my application for the Client Assistance Program and will not be used for any other purpose other than eligibility determination for the Client Assistance Program. I understand the request for Mental Health Client Assistance Program funding and I agree with this request for assistance. I understand that the consent will automatically expire one year from the date of my signature. I understand that I may revoke this consent at any time upon written notice (not retroactive) and if I revoke my consent to share information with Watonwan County Human services my eligibility for the Mental Health Client Assistance Program will also be revoked.Client/Legal Guardian Signature(Required) First Last Date(Required) MM slash DD slash YYYY CAPTCHA
