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West Virginia Income Maintenance Manual Acronyms, Forms, and Glossary

West Virginia Income Maintenance Manual Page 21

Acronyms, Forms, and Glossary

Form Abbreviation/Code Form Name Chapter (s) DFA-FTI-1 Disclosure of Federal Tax Information 6 DFA-HIP-1 Certificate of Medical Coverage 10, 22, 23 DFA-HS-3 Referral to Social Security Administration 2, 24 DFA-HV-1 Missed Home Visit 1 DFA-ICF/MR-1 Pre-Admission for ICF/MR 24 DFA-ID-1 Identity Declaration 7 DFA-IE-01 IRS Disclosure Notice Log 6 DFA-IE-02 IRS Safeguard Log 6 DFA-J-1 JOIN Individual Participation Agreement 18 DFA-J-3 JOIN Contract 18 DFA-J-3A JOIN Addendum/Renewal 18 DFA-JD-1 Job Experience Description 18 DFA-LIEAP-1 LIEAP Application 1, 21 DFA-LIEAP-1a Instructions for Completing the Application Form 21 DFA-LIEAP-1b Supplement to LIEAP Application 1, 21 DFA-LIEAP-3 Repayment Agreement 21 DFA-LIEAP-4 Zero Income/Home Heating Cost 21 DFA-LIEAP-5 Authorization for Delivery and Payment of Emergency/ Regular LIEAP 21 DFA-LIEAP-6 LIEAP Application Log 21 DFA-LIEAP-8 LIEAP Repayment Tracking Form 21 DFA-LIEAP-ERR-1 Application for Emergency Repair and Replacement 1 DFA-LTC-5 Application for Long Term Care Services for Current Medicaid Recipients 24 DFA-LTCIP-1 Long-Term Care Insurance Partnership Policy Verification 7, 24 DFA-MA-1 Medical Assistance Application 1, 24 DFA-NH-3 (NMNH) Contribution to the Cost of Care Notice 24 DFA-NL-5 Waiver of 13-Days Advance Notice 9