ࡱ> mol @ Hbjbj{{ *`' %lllllllh#h#h#8#<#.,$&&&&'(Tm(,.......$/RN2B9.Ql(''((9.ll&&.)))(l&l&.)(.))ll)&$ F\J/Sh#()'*.0.)3(3)llll3l)|(()(((((9.9. )FEDERAL COMPLIANCE OFFICE (FCO) DECISION TO ADMINISTRATIVE REVIEWREQUEST FOR DETERMINATION OF CARE (DOC) DENIALMichigan Department of Human ServicesA. IDENTIFYING INFORMATION Child s Name (Last, First, Middle)Birthdate FORMTEXT       FORMTEXT      SWSS Log NumberSWSS Case Number FORMTEXT       FORMTEXT      DHS Worker-Printed NameDHS Worker SignatureLoad Number FORMTEXT       FORMTEXT      DHS Supervisor-Printed NameDHS Supervisor Signature FORMTEXT      Private Agency Name FORMTEXT      Agency Worker-Printed NamePrivate Agency Worker SignatureAgency Worker Email FORMTEXT       FORMTEXT      Agency Supervisor-Printed NamePrivate Agency Supervisor SignatureAgency Supervisor Email FORMTEXT       FORMTEXT      Foster Parent Name FORMTEXT      Foster Parent Address/City/State/Zip FORMTEXT      Foster Parent PhoneFoster Parent Email FORMTEXT      FORMTEXT       FORMTEXT      B. ADMINISTRATIVE REVIEW INFORMATION Date Administrative Review Request Received by FCODate of Administrative Review Decision FORMTEXT       FORMTEXT      Review Requested by:Local DHS Office FORMCHECKBOX Private Agency FORMCHECK(8D< > B p v     " $ B D d h j ~ ºŸ}jh-Uh-jh-UjhUjhUhh)OJQJjhdUjhh)UjhV/UmHnHujhdUjhZ UhZ hh)hZ 5 hh)5hh)hhjd1s6<kd$$Ifl4,,4 lalf4<kdX$$Ifl4,,4 lalf4 $Ifgdjd<kd$$Ifl4p,,4 lalf4 $Ifgd(,NHH6 8 : < t s]$ ($If^a$gdd<kd`$$Ifl4,,4 lalf4 $Ifgd(,<kd$$Ifl4,,4 lalf4 $Ifgdjdt v " VG:  $IfgdZ  $IfgdZ Okd$$Ifl40, 4 lalf4  $IfgdZ  $IfgdZ <kd$$Ifl4P,,4 lalf4" $ D f h PAA $IfgdZ Okd$$Ifl40<,<K4 lalf4 $IfgdZ Okd$$Ifl4P0, 4 lalf4 , . 0 D F H R T X Z n p r | ~        D F H J ^ ` b l n p r ﰻû裟ãxtixxj* hUhjhUhh)h%Y5hh)hh)5h%YjlhDUhDjhDU hh)5jhdUjhh)UjhV/UmHnHuj~hb/ Uhb/ jhb/ U hh)5CJhh)hjdjh-U(  , . 0bkd$$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ Okdd$$Ifl4P0<,<K4 lalf4. V X qbb $IfgdZ bkdR$$Ifl4PFV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ      A2 $IfgdZ Okd$$Ifl4P0V,V14 lalf4 $IfgdZ  $IfgdZ Okd$$Ifl40V,V14 lalf4  F H p vg $IfgdZ <kd $$Ifl4,,4 lalf4 $IfgdZ <kdX $$Ifl4,,4 lalf4p r   Cbkd $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ <kd $$Ifl4P,,4 lalf4r    ( * , 6 8 < > R T V ` b d f  468BDHJ^`blnvĹЬЬx hZ hZ jhb/ Uhh)hZ 5jhDUj hDUhDjhDU hZ 5j hUhjhUjhV/UmHnHuj hb/ Uhb/ jhb/ U hZ 5CJhZ . : < d f qbbU  $IfgdZ  $IfgdZ bkdx $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ FHp~u $IfgdD $IfgdZ  $IfgdZ bkd $$Ifl4FV,V      4 lalf4prtvP<kd$$Ifl4,,4 lalf4 $IfgdZ bkd|$$Ifl4FV,V      4 lalf4vg $IfgdZ <kdP$$Ifl4P,,4 lalf4 $IfgdZ <kdz$$Ifl4,,4 lalf4<>fvgg $IfgdZ <kd$$Ifl4P,,4 lalf4 $IfgdZ <kd$$Ifl4,,4 lalf4*,.8:<>  8N   "$.024H󰬡ڰՑjDhZ Uhhh)hZ 5hZ hZ 5j`hb/ Uhb/ jhb/ UjhdUjhdU hZ 5CJ hZ 5jhV/UmHnHuj(hZ UhZ jhZ U1RP8$ ($If^a$gddOkd$$Ifl4P0V,V14 lalf4 $IfgdZ Okd $$Ifl40V,V14 lalf4RT 2ZcTT $IfgdZ Okd$$Ifl40<,<K4 lalf4 $IfgdZ <kdV$$Ifl4P,,4 lalf4HJLVX\@@ @ @*@,@H@J@L@N@P@R@T@AAA ABAAAAAAAAֲֽֿ֧֝ڌڌڌڄ|xm|jhV/Uh]2jh]2UhZ h]25hdhZ hZ 5 hZ 5hCJOJQJjhV/Uj"hV/UUh6\JjhV/UjhUhhZ jhV/UmHnHujhZ UjhZ U(Z\@*@N@ $Ifgd $IfgdOkd,$$Ifl4P0<,<K4 lalf4BOX Foster Parent FORMCHECKBOX C. An administrative Review of this Determination of Care assessment has been conducted by the Federal Compliance Office. Below is the finding and reason behind the decision: FORMCHECKBOX Original decision upheld. Effective date of DOC level: FORMTEXT      Reason: FORMTEXT       FORMCHECKBOX Original decision overturned. Effective date of DOC level: FORMTEXT      Reason: FORMTEXT      D. The local DHS office must make payment authorization adjustments necessary to comply with this decision within 10 calendar days of this notice.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. 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