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1016 Verification of Marriage - form used to verify marriage. 1020 Referral to Medical Review Team - cover sheet for submitting the medical packet to MRT. Original forwarded, copy in record. 1049 Verification of Vital Event - form used for confirmation of birth or death in the District of Columbia. 1052 Record of Case Action - dictation sheet for case actions that is kept in the case record. 1209 Medicaid Recertification Form [PDF] [English] [En Español] - form used to re-determine Medicaid eligibility for non-TANF MA cases. 1209 W Medicaid Recertification Form - form used by District agencies to report Medicaid eligibility recertification information for customers enrolled in Medicaid Waivers and Demonstrations. 1210 Medicaid Recertification Worksheet [PDF] - form used to determine the appropriate procedure for processing a Medicaid recertification form that is returned by the customer. 1288/A Notice To Child Support Agency - form used to report information about absent parent(s) to the Child Support Enforcement Division (CSED). Original plus one copy to IV-D and copy in record. 1348 Request for a Fair Hearing - form completed by applicant/recipient or Agency representative to report request for a fair hearing. Original forwarded, copy in record. 1356 Manual Application Checklist - form used to request information needed to determine program eligibility from applicants when ACEDS is inoperable. Original to applicants, copy in record. 1400 Notice to Applicants [PDF] - form that notifies applicants of their rights. Original to applicant, copy in record. 1503 Redetermination of Eligibility - form generally used to schedule a TANF review. Form can also be used to gather additional needed information from applicants/recipients in any ESA program. Original to applicant/recipient, copy in record. 1549 Verification of School Attendance - form required for all TANF children 16 years of age and older to verify that a minor child is enrolled and/or attending school. This form can also be used to verify "Living With" and residency. Returned form is kept in case record. 1673A Insurance Reporting Form (Third Party Liability) - form used to notify the Medical Assistance Administration of private health insurance coverage. Information must be entered on ACEDS "HEIC" screen. Original forwarded, copy in record. 1673B Notice of Potential Medicaid Payment Recovery - form used to report potential resources such as lawsuit or workman's compensation to MAA. Original forwarded, copy in record. 1692 Countable Medical Expenses - form lists medical expenses incurred during the six month prospective period for spend-down cases. Original in record.