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The release must be signed by the a/b or the a/b’s guardian, if

appropriate, dated, with an end date no longer than 12 months from the

date of signature, and is specific in what information is to be released.

B. Two forms are available for communication between the

DSS IMC and the LME/MCO transition or care coordinator.

1. The DSS-0033 Appendix E, Supplement 1 is a form for the DSS IMC to communicate with the LME/MCO transition coordinator or care coordinator.

2. The DSS-0034 Appendix E, Supplement 2 is a form for the LME/MCO

transition or care coordinator to communicate with the DSS IMC.

C. Providing Income Information to the LME

The DSS may share Medicaid eligibility information and the following

income information:

1. The amount of gross income before any deductions or exclusions (for

earned income, Medicare premiums, etc. or for any exclusion including

the $20 general income exclusion.)

2. Source of income that is obtained through electronic matches cannot

be shared. (Electronic data matches include matches from the Social

Security Administration, Veterans’ Administration, and the

Employment Security Commission.) The amount of income can be

shared, but not the type (SSI, RSDI, VA., etc.) Only provide the source

of the income if it is verified through a source other than an electronic

data match.

D. It is critical that the LME Transition Coordinator receives all

eligibility correspondence.

Once the approval for TLC is verified, and an appropriate release of

information has been obtained, enter the LME/MCO contact information

onto the Client Contact Tab of the Person Page in the NC FAST.

VII. Request from the LME/MCO for SAIH for Individuals

Approved for TCL

SA-5250 VI-VII.