SOAR OAT Data Form. Yes (check all that apply): TANF Medicaid General/Public Assistance No Don t Know

Size: px

Start display at page:

Download "SOAR OAT Data Form. Yes (check all that apply): TANF Medicaid General/Public Assistance No Don t Know"

Dwight Dixon
5 years ago
Views:

SOAR OAT Data Form Applicant and Person Assisting Applicant Information (not collected in OAT) Name of Person Assisting Applicant: Agency Name: Phone Number: Applicant First Name: Email: Date of

1 SOAR OAT Data Form Applicant and Person Assisting Applicant Information (not collected in OAT) Name of Person Assisting Applicant: Agency Name: Phone Number: Applicant First Name: Date of Birth: (mm/dd/yyyy) SS#: Demographics Gender: Female Male Age: Applicant Last Name: Military Service? No (Skip for child applicants) If yes: Military Discharge Status: Was applicant receiving VA Disability Compensation at time of application? Was the applicant receiving county, state or other public assistance (cash or health insurance) prior to applying for SSI/SSDI? Was the applicant working during the application process? (check all that apply): TANF Medicaid General/Public Assistance Working Earnings per month: $ What was the applicant s housing status at the time of the application? Outdoors (e.g. street, abandoned or public building) Shelter Transitional Own or someone else s apartment, room or house SRO, boarding house Residential treatment for adults Institution (psychiatric or other hospital, nursing home, etc.) Jail or correctional facility Housing First HUD funded voucher Permanent Supportive Housing Foster care Residential facility for children or youth Unaccompanied youth Fleeing domestic violence Length of time homeless (i.e. length of time homeless prior to working on the SOAR application or prior to entering the current housing situation): years and months Application Type (Please check one) Initial SOAR Application - Filing an initial SSI/SSDI application with SSA (Complete section A only) Reconsideration using SOAR Initial application was denied and you are filing a Request for Reconsideration (Complete section B only) Administrative Law Judge (ALJ) Hearing using SOAR Reconsideration denied (or prototype state) and you are filing a Request for ALJ Hearing (Complete section C only) n-soar Claim Not a SOAR applicant and no SOAR critical components are used (Complete section D only)

2 Section A: Initial SOAR Application Protective filing date (initial contact with SSA) Were medical records collected and submitted? Was a Medical Summary Report (MSR) written and submitted? Yes Yes Yes Yes Yes Has a complete application packet been submitted to SSA? Was a Consultative Exam (CE) ordered? Yes Application date (packet submitted to SSA): / / Application will not submitted to SSA due to: Moved Disappeared Incarcerated Withdrew Transferred to new representative Other: Has there been notification of a decision? Case is still pending Date of final decision: (Go to Post- Questions) significant impairment Failure to cooperate n-medical Was a reconsideration or appeal filed? My state doesn't have reconsideration, filed appeal B. Reconsideration Using SOAR Date of request for reconsideration Were additional medical records collected and submitted? Was a Medical Summary Report (MSR) written and submitted? Was a Consultative Exam (CE) ordered? Yes Yes Yes Yes Yes Yes

3 Has there been notification of a decision? Case is still pending Date of reconsideration decision: (Go to Post- Questions) significant impairment Failure to cooperate n-medical Was a request for an ALJ hearing submitted? C. Administrative Law Judge (ALJ) Hearing using SOAR Date of request for ALJ hearing Was an expedited hearing requested? Was a review on record requested? Were additional medical records collected and submitted? Was a Medical Summary Report (MSR) submitted? Did the applicant have an attorney? Was a Consultative Exam (CE) ordered? Yes Yes Yes Yes Yes Yes Date of ALJ hearing: Date of decision on ALJ: (Go to Post- Questions) Outcome of ALJ hearing significant impairment Failure to cooperate n-medical

4 D: Non-SOAR Claim Date of first contact with applicant whose claim was pending: When you began working with applicant, application was pending at the: (complete A, B, or C) (Go to Post- Questions) (Go to Post- Questions) (Go to Post- Questions) A. Initial Level Date of initial decision: significant impairment Failure to cooperate n-medical Was a reconsideration or appeal filed? My state doesn't have reconsideration, filed appeal B. Reconsideration Level Date of reconsideration: significant impairment Failure to cooperate n-medical Was a request for an ALJ hearing submitted? C. Administrative Law Judge (ALJ) hearing level Date of ALJ hearing: Date of decision on ALJ / / / / Outcome of ALJ hearing significant impairment Failure to cooperate n-medical

5 Post- (for ALL approvals) for SSI/SSDI? SSI Only SSDI Only Both SSI/SSDI SSI Award per Month: $ SSDI Award per Month: $ Medicaid Reimbursement Amount (in dollars): $ Medicare Reimbursement: Amount (in dollars): $ General/Public Assistance Reimbursement Amount (in dollars): $ Retro Back payments (in dollars): $ Is the Applicant Working Post- (at time of decision)? If yes, Post- Earnings per Month (in dollars): Was applicant housed at time of decision? If yes, did access to benefits facilitate housing? Representative payee needed? If yes, Representative payee provided? # Hours to Complete Claim: $

Respond to the following questions for all household members each adult and child. A separate form should be included for each household member.

Respond to the following questions for all household members each adult and child. A separate form should be included for each household member. HMIS Data Collection Template for Project EXIT CoC Program This form can be used by all CoC-funded project types: Street Outreach, Safe Haven, Transitional Housing, Rapid Rehousing, and Permanent Supportive