CLIENT BENEFITS EVALUATION
Michigan Department of Health and Human Services
HIV Continuum of Care Unit
Fill out this form as completely as possible. Accurate information is essential in order to make a complete estimate of the programs for which your client may be eligible.
Case Manager:	Agency:
Agency Phone No.:	Ext. No.:	Agency Fax No.:
Email Address	Date Completed	Evaluate for:
Initial or Reassessment and/or ADAP
IF YOU ARE REQUESTING AN ADAP ASSESSMENT, YOUR CLIENT MUST HAVE A SOURCE OF VERIFIABLE INCOME. Please fax one full month’s verification (pay stub, award letter, etc.). You do not have to fax verification of SSI, SSDI, or SDA. IF THERE IS NO INCOME, YOUR CLIENT MUST GO TO MDHHS AND APPLY FOR MEDICAID AND/OR HEALTY MICHIGAN PLAN.
Client Information:
Name: (Last, First, Middle Initial)	D.O.B.
City:	County:	S.S.N.
Living Arrangements:
Client Lives Alone	OR	Client Lives With: (Check all that apply)
Spouse	Parents	Partner
Girlfriend or Boyfriend	Friends	Roommates
# of children under 18
# of children over 18
Other
Total family size
If client lives with others, does he/she purchase and prepare food separately?	Yes	No
Disability:
Case Managers – Check off ALL that apply:
Client has an AIDS diagnosis (not HIV), confirmed by a doctor.
Client is unable to perform any substantial gainful activity (not able to make $1130/month gross earned income) AND suffers from an incapacity or disease that is expected to last 12 months or longer or results in death.
Client has a physical or mental impairment prohibiting him/her from earning substantial gainful activity ($1130/month gross earned income) that will last 90 days or longer.
Client is on Medicaid or Medicaid deductible, and in need of someone else to provide help with eating/feeding, toileting, bathing, grooming, dressing, mobility, laundry, meal preparations, errands light, housekeeping, etc.
Is the client a U.S. citizen?
Yes	No	If no, client’s Alien Registration #
Is the client an undocumented alien?	Is client a veteran?
Yes	No	Yes	No	If yes, how many years of service?
Income:

(Enter monthly amount received)	Assets:
TYPE	MONTHLY AMT.

RECEIVED
TYPE OF ASSETS	AMOUNT
FIP/TANF
Checking Account
Child Support
Savings Account (Enter total if more that one)
Employment/Wages

(enter gross amount)
Certificates of Deposit
Other Family/Household Income
Money Market Account
Pension
Stocks or Mutual Funds
Rental Income
Cash on Hand or in Safety Deposit

Box
SSA Retirement
IRA/KEOGH/401(k)
SSDI
Other Cash Assets
SSI
TOTAL ASSETS
State Disability Assistance (SDA)
NOTES
Unemployment (UCB)
VA Benefits
Workers’ Comp
Other Income
TOTAL INCOME*
*If no income is listed, and client lives alone, how does he/she pay shelter and living expenses?
Monthly mortgage (includes taxes) or rent amount:	Monthly FAP (Food Stamps) amount received:
Does client have any real estate or property, not including current residence?
Yes	No
Does the client have more than one vehicle registered in his or her name at the Secretary of State?
Yes	No
Has the client left work within the last six months?
Yes	No	If yes, when?
Medical Insurance Information:
What medical insurance does the client currently have? (Check all that apply)
Medicaid
Medicaid Deductible	Healthy Michigan Plan
Medicaid HMO	Insurance Assistance Program
Straight/Full Medicaid	Full Drug Assistance Program
Co-pay Drug Assistance Program
Medicare
Part A	Part B
Medicare Supplemental Plan (Medigap)
Veterans Insurance
Private Medical Insurance (e.g., BC/BS) (Check all that apply)
Employer Paid	COBRA	Conversion Policy
Prescription Coverage	No Prescription Coverage	Individual Policy
Co-pay amount $
NO MEDICAL INSURANCE
Does client have any unpaid medical bills?	Yes	No
Out of Pocket Medical Expenses:
If the client pays out of pocket for any of the following medical expenses, list the monthly amount for each:
TYPE OF EXPENSE	MONTHLY AMOUNT
Medical Care
Dental Care
Hospitalization
Prescription Drugs (including co-pays)
Over the Counter Medications Recommended by Licensed Health Provider
Medical Supplies/Equipment Prescribed by Doctor
Premiums for Health/Hospitalization Insurance
Medicare Premiums
Dentures, Hearing Aids, Prosthetics, Eyeglasses
Cost of Transportation to Secure Medical Treatment
Cost of Employing an Attendant Homemaker, Home Health Aide, Housekeeper or Chore Provider due to Age or Illness
TOTAL
Authorization to Release Information
I,
give permission to
(print client name)
(print agency name)
to exchange information I have provided in this Client Benefits Evaluation form with the Michigan Department of Health and Human Services. I understand that information provided on this form will be used to evaluate my possible eligibility for welfare entitlement benefits (i.e., Social Security Disability Insurance, Medicaid, Food Assistance Program, etc.) other government benefits (i.e., Michigan Drug Assistance Program, Insurance Assistance Program, etc.), and other community resources and/or benefits.

I understand that the information I provided on this evaluation form will be verified by computer cross-checking with other government, public and/or private agencies. The information obtained through this cross-checking may be verified through collateral contact when/if discrepancies are found. The information may affect both my evaluation for and level of benefits. I authorize the Social Security Administration to give to Michigan Department of Health and Human Services all information necessary to evaluate my eligibility for benefits including, but not limited to Medicaid, Food Assistance Program, State Disability Assistance, etc.

I understand that if I am evaluated to be eligible for assistance based on information I have provided on this form, that I will need to complete and submit application(s) for those programs to Michigan Department of Health and Human Services and/or Social Security Administration. These entities will make the final determination of my eligibility for these programs.

I certify that all information that I have written on this form or told to my case manager is true. I also know that if I have intentionally left out any information or if I have given false information that this may affect my evaluation for benefits and/or resources.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.	Response: Voluntary

Penalty: None
Client Signature:	Date:	Witness Signature:	Date:
Guardian Signature:	Date:	Witness Signature:	Date:
This release expires one year from date of signature above. When completed, fax this from to 517-335-7723.

DHS-424 (Rev. 2-16a) Previous edition obsolete.	2

DHS-0424, Client Benefits Evaluation Form

Comp

2008-07-07

Putman, Andrea (DHS)

State of Michigan