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West Virginia Income Maintenance Manual Acronyms, Forms, and Glossary

West Virginia Income Maintenance Manual Page 23

Acronyms, Forms, and Glossary

Form Abbreviation/Code Form Name Chapter (s) DFA-RT-7 Specialist Consultation 13 DFA-RT-8 Request from Physician's Record 13 DFA-RT-8a Physician's Summary 13 DFA-RT-9 Report from Hospital Records 13 DFA-RT-10 Inpatient Diagnostic Services 13 DFA-RT-11 Physician's Hospital Services 13 DFA-RT-15 Psychiatrist's Billing Form 13 DFA-RT-15a Psychiatrist’s Summary 13 DFA-RV-1 Recreational Vehicle Estimate 7 DFA-SEBT-1 Summer EBT application 20 DFA-SLA-1 Single Streamlined Application for Healthcare Coverage 1, 24, 26 DFA-SLA-2 Single Streamlined Application for Healthcare Coverage- Short Form 1, 24, 26 DFA-SLA-S1 Application for Health Care Coverage 1, 22, 24 DFA-SNAP-1 Supplemental Nutrition Assistance Program Application 1 DFA-SNAP-2 SNAP Change Reporting Form 10 DFA-SNAP-36 SNAP Benefits Replacement 12 DFA-SNAP-E&T-1 SNAP E&T Personal Responsibility Plan 17 DFA-SNAP-E&T-2 SNAP E&T Notification Form 17 DFA-SNAP-E&T-4 SNAP E&T Self-Sufficiency Appraisal 17 DFA-SNAP-E&T-PD SNAP Provider Determination 3, 17 DFA-SNAP-E&T-TA SNAP E&T Training Agreement 17 DFA-SNAP-I&R1 Information and Referral Guide 1 DFA-SP-1 Application for Special Pharmacy 1, 28 DFA-SS-2 Continued Sup. Serv. Application 18 DFA-SSP-1 WV WORKS Self-Sufficiency Plan 18 DFA-SSP-1a WV WORKS Goal Action Plan 1, 18 DFA-TA-2 Tel-Assistance/Lifeline Application 20