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West Virginia Income Maintenance Manual Acronyms, Forms, and Glossary

West Virginia Income Maintenance Manual Page 22

Acronyms, Forms, and Glossary

Form Abbreviation/Code Form Name Chapter (s) DFA-NL-6 Notice of Withdrawal of Application 9 DFA-NL-A Notification Letter: Action Taken On Your Application 9, 16, 24 DFA-NL-B Notice of Decision - Redetermination 9, 24 DFA-NL-C Notice of Decision - Change 9, 13, 18, 24 DFA-NL-D Asset Assessment - Notice of Decision 24 DFA-NL-MN-1 AFDC-Related Medicaid Computations 9 DFA-NL-SNAP-1 SNAP Computations 9 DFA-NL-UH-1 Right to Request Undue Hardship Waiver 24 DFA-NL-UH-2 Notice of Decision - Request for Undue Hardship 24 DFA-PAC-4 Pickle Medicaid Review 1 DFA-PHI-1 Authorization for Information 13 DFA-PRC-1 WV WORKS Personal Responsibility Contract 1, 18 DFA-PRC-2 Interim Contact Form 1, 10 DFA-PSSE Periodic Self Sufficiency Evaluation 18 DFA-PVM-1 Prisoner Verification Match

DFA-QSQ-1 QMB/SLIMB/QI Application 1 DFA-R-1 Pre-Employment Services Project Referral - Vision/Dental Services 18 DFA-REF-1 Referral & Information Form 15 DFA-REF-2 Reverse-Referral & Information Form 15 DFA-RFA-1 Request for Assistance 1 DFA-RR-1 Rights and Responsibilities 1, 4, 6, 20, 24 DFA-RT-1 Social Summary 13 DFA-RT-2 MRT Transmittal Form 13 DFA-RT-3M Mental Disability/Incapacity Evaluation Form 1, 13 DFA-RT-5 Adult - General Physical 13 DFA-RT-5a Child - General Physical 13 DFA-RT-6 Medical Information/Diagnostic Request Letter 13