Developmental Disabilities Administration Intake Questionnaire

(To be completed by the parent/legal guardian of a child applicant or by the adult applicant)

-:C+ \s he-le ~t.tl +o . o.~~t.oe.x '}CAe.s+-ion ±F- { u.>i+'h ret1A.es+-s .Peir spec.it:i·c S~fvl(~""s Why are you seeking DOA services? What do you hope will happen as a result of

becoming eligible for DOA services?

w ~ Y'-eed r:~s ri +~ 6 P...

-1< fo,...5we~i..,ll!J +ht·s ~LLtShun ~· o.,':j__ h~lp C..~f\t\t.d- you.. -fo 5€t'VflL5 Mort: cr-u;c.l:.l~ What is working well for you right now?

What is not working well right now?

What community agencies are you currently connected with and receive supports

from?

FOR OFFICE USE ONLY

mnt w .. hi noton SI> " DEVELOPMENTAL DISABILITIES ADMINISTRATION (DOA) D Initial 0 Reapplication J Department of Social

Request for ODA DDA NUMBER: & Health Services

Transforming lives

Eligibility Determination lj·: 1i': 'I, '" ... ,:11 :1:,:'"!"1 ,,,,," 11111 I

Applicant Information ' ~ ' I 11: II :11. ,,; ,,;ii," ",,. , .. ,1

1. ,f' ii' 'i .1., "' ',., .. ":'·ftl >,'

LAST NAME FIRST NAME MIDDLE NAME/INITIAL I BIRTHDATE SOCIAL SECURITY NUMBER

Sunshine Rosie L 04/22/2007 123-00-4567 ADDRESS CITY STATE ZIP CODE

1234 Commercial St Bellingham WA 98225

MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE COUNTY

HOME TELEPHONE NUMBER (including Area Code) I OTHER TELEPHONE NUMBER (including Area Code} GENDER

360-555-5555 0 Work D Cell D Message D Male ~ Female

MARITAL STATUS OF APPLICANT EDUCATION

D Divorced D Separated ~ 81h Grade or less D Bachelor's Degree

D Married D Unmarried Partner D 9 - 11 Grades D Graduate School

~ Never Married D Widowed D High School D No Schooling

D Technical or Trade School

Does the applicant have a representative? D Yes D No If yes, name this person:

APPLICANT'S USUAL HOUSING SITUATION

D Adult Family Home D Nursing Facility D Own Home (with others)

D Child Foster Home D Other's Home ~ Parent's Home

D Group Home D Own Home (alone): D Own D Rent D Subsidized 0 Relative's Home

D Homeless D Own Home (spouse/partner D State institution, psychiatric

D Correctional Facility D Own Home (with dependent children) D Unknown

D Licensed Staff Residential I "''«'"·"'''''!1 1

·n ' '' ., :1i1

,,,:,,ii[1'11 .:;H1!1I!: " i

Contact Person 11, ti'· )1;: Id· I"

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"" '' ' ',,,,.

NAME I RELATIONSHIP

Julie Sunshine mother MAILING ADDRESS CITY STATE ZIP CODE

same as above HOME TELEPHONE NUMBER (including Area Code) OTHER TELEPHONE NUMBER (including Area Code) E-MAIL ADDRESS

D Work ~Cell D Message jsunshine@gmail.gov 360-111-1111

MAIL CONTACT I RELATIONSHIP TYPE/ROLE I LEGAL RELATIONSHIP LIVES WITH APPLICANT

~Yes D No parent ~Yes 0 No

I, I 'I!:: "' 'lil'ii "' 1,,, ,,,,,,,. 11! 'it· !'I

DESCRIBE THE DISABILITY AND THE AGE AT WHICH IT WAS OBSERVED.

Autism Spectrum Disorder Speech delay noted at 24 months

SIGNATURE OF ADULT APPLICANT DATE

SIG~- OF REPRE-=~IVE I LEGAL RELATIONSHIP DAT:;C /, - pqre,,..+- 'f t.L '/ft:, '-- ~ - __.....- I />.

~- ..,___. ( I ' DSHS 14-151 (REV. 01/2015)

SOURCE OF PERSONAL INCOME OF APPLICANT: CHECK ALL THAT APPLY

D Social Security D Veteran's Administration D Civil Service

D Supplemental Security Income (SSI) D Bureau of Indian Affairs (BIA) rgi None

D General Assistance-Unemployable (GA-U) D Railroad retirement D Other (specify below):

D State Supplemental Payment D Trust funds

D Temporary Assistance for Needy Families (TANF) D Earned income

Does the Applicant have any kind of Medical Coverage? [8'.J Yes D No Medicare? D Yes [8'.J No lfves

If yes, please list. MEDICARE NUMBER I TYPE

Regence A ETHNIC CODES ·(CHECK THE CORRECT CODE(S) BELOW)

fgj White D Chinese Native Hawaiian/ Other Pacific B. Is the applicant Hispanic?

D Filipino Islander 1:8'.l No American or Alaska Native D D Eskimo D Japanese Hawaiian D Not Reported

D Aleut D Korean D Samoan D D D Guamanian

Yes (If yes, indicate)

D American Indian Laotian D D D Other Asian/Pacific Islander Cuban Thai D Asian D Vietnamese D Other race Mexican/Mexican American/Chicano

D Asian Indian D Unreported D Puerto Rican

D Cambodian D Black or African American D Other Spanish/Hispanic

PRIMARY LANGUAGE I SPEAKS ENGLISH I UNDERSTANDS ENGLISH I INTERPRETER REQUIRED I TRANSLATIONS REQUIRED

English [8'.J Yes D No D Limited 1:8'.l Yes D No D Limited D Yes [8'.J No D Yes [8'.J No

PRIMARY SIGNIFICANT OTHER NAME I STREET ADDRESS CITY STATE ZIP CODE A Skip this section

TELEPHONE NUMBERS I MAIL CONTACT I RELATIONSHIP TYPE/ROLE I LEGAL RELATIONSHIP TYPE/ROLE I LIVES WITH APPLICANT D Yes D No D Yes D No

SIGNIFICANT OTHER NAME I STREET ADDRESS CITY STATE ZIP CODE B Skip this section

TELEPHONE NUMBERS I MAIL CONTACT I RELATIONSHIP TYPE/ROLE I LEGAL RELATIONSHIP TYPE/ROLE I LIVES WITH APPLICANT D Yes D No D Yes D No

SIGNIFICANT OTHER NAME I STREET ADDRESS CITY STATE ZIP CODE c Skip this section

TELEPHONE NUMBERS I MAIL CONTACT I RELATIONSHIP TYPE/ROLE I LEGAL RELATIONSHIP TYPE/ROLE I LIVES WITH APPLICANT D Yes D No D Yes D No

FOR PERSONS UNDER 22 YEARS OF AGE

NAME OF SCHOOUDAY PROGRAM START DATE

Sunnyland Elementary School ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER

SCHOOL DISTRICT NAME

Bellingham School District COMMENTS

DSHS 14-151 (REV. 01/2015)

ttit w" "''"' '" '' 7 Department of Social

& Health Services CONSENT NOTICE TO CLIENTS: The Department of Social and Health Services (DSHS) can help you better if we are able to work with other agencies and professionals that know you and your family. By signing this form, you are giving permission for DSHS and the agencies and individuals listed below to use and share confidential information about you . DSHS cannot refuse you benefits if you do not sign this form unless your consent is needed to determine your eligibility. If you do not sign this form, DSHS may still share information about you to the extent allowed by' law. If you have questions about how DSHS shares client confidential information or your privacy rights, please consult the DSHS Notice of Privacy Practices or ask the person giving you this form.

CLIENT IDENTIFICATION: NAME I DATE OF BIRTH I IDENTIFICATION NUMBER

Rosie Sunshine 04/22/2007 skip this section ADDRESS CITY STATE ZIP CODE

1234 Commercial St Bellingham WA 98225 TELEPHONE NUMBER (INCLUDE AREA CODE) I OTHER INFORMATION

360-555-5555 CONSENT:

I consent to the use of confidential information about me within DSHS to plan, provide, and coordinate services, treatment, payments, and benefits for me or for other purposes authorized by law. I further grant permission to DSHS and the below listed agencies, providers, or persons to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, or hand delivery.

Please check all below who are included in this consent in addition to DSHS and identi~ them by name and address:

[8J Health care providers: Roy Raincloud, MD--PeaceHealth Pediatrics; Seattle Children's Hosnital Autism Center [8J Mental health care providers: Sandra Snow, MD (ns:ychiatrist} D Chemical dependency service providers:

D Other DSHS contracted providers:

D Housing programs: [8J School districts or colleges: Bellini:ham School District D Department of Corrections:

D Employment Security Department and its employment partners:

D Social Security Administration or other federal agency: [8J See attached list

D Other:

I authorize and consent to sharing the following records and information (check all that apply): [8J All my client records D Records on attached list

D Only the following records D Family, social and employment history D Health care information D Treatment or care plans D Payment records D Individual assessments D School, education, and training

D Other (list):

PLEASE NOTE: If your client records include any of the following information, you must also complete this section to include these records.

I give my permission to disclose the following records (check all that apply): [8J Mental health D HIV/AIDS and STD test results, diagnosis, or treatment D Chemical Dependency (CD) services

- This consent is valid for 0 one year 0 as long as DSHS needs records, or 1:83 until 04/22/2017 (date or event).

- I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared.

- I understand that records shared under this consent may no longer be protected under the laws that apply to DSHS.

- A copy of this form is valid to give my permission to share records. SIGNATURE I DATE AGENCY CONTACT/WITNESS SIGNATURE DATE

/'I PA~OR OTHER RE~ATIVE'; SIGNATURE (IF APPLIC~LE) TELEPHONE NUMBER (INCLUDE AREA CODE)

DAT? : J I. /.;0 A ii- z.2, J b

1«c -.....:; -am not the subject of the records, I am authorized to sign because I am the: (attach proof of authority) I I I

[8J Parent D Legal Guardian (attach court order) D Personal representative D other:

NOTICE TO RECIPIENTS OF INFORMATION: If these records contain information about HIV, STDs, or AIDS, you may not further disclose that information without the client's specific permission. If you have received information related to drug or alcohol abuse by the client, you must include the following statement when further disclosing information as required by 42 CFR 2.32:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medial or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

. DSHS 14..012(X) (REV. 02/2003)

INSTRUCTIONS FOR COMPLETION OF CONSENT FORM

Purpose: Use this form when you need consent to use confidential information on a continuing basis about a client within DSHS or to disclose that information to other agencies to coordinate services or for treatment, payment or agency operations or for other purposes recognized by law. Clients are persons receiving benefits or services from DSHS.

Use: Fill out this form electronically if possible for ease of reading, A separate form must be completed for each person, including children. "You" in the instructions refers to the DSHS employee and "you" on the form refers to the client. Sharing of records includes the use and disclosure of confidential information about a client.

Parts of Form:

IDENTIFICATION:

- Name: Provide the name of one client only on each form. Include any former names that client may have used when receiving

services.

- Date of Birth: Needed to identify client from persons with similar names.

- Identification Number: Provide a client identification number or other identifier such as a social security number (not required) to assist in identifying records and tracking history and services received.

- Address and telephone: Additional information that will help in locating and identifying or contacting the client.

- Other: Include in this box any additional information that may help to locate records that may include parts of DSHS involved with services, names of family members, or other relevant information.

CONSENT (AUTHORIZATION):

- Agencies or persons exchanging records: The client's completion of this form allows the use and sharing of confidential information within all of DSHS. DSHS will be able to disclose to and receive confidential information from the outside agencies or persons listed. Provide identifying information about the agencies or providers, including name, address or location if possible. You may also attach a list of agencies allowed to share information which the client must also sign.

- Information included: Clients must indicate what records are covered by the consent. Clients may make all records available or may limit the included records by date, type or source of record. If a client does not sign a consent or does not specify a particular record, sharing of that record will still be allowed if permitted by law. You may attach a list of covered records that the client must also sign. If any records include information relating to mental health (RCW 71.05.620), HIV/AIDS or STD testing or treatment (RCW 70.24.105), or drug and alcohol services (42 CFR 2.31 (a)(5)), the client must mark these areas specifically to give permission to share these records. This form is not valid to include psychotherapy notes under 45 CFR 164.508(b)(3)(ii) and a separate form must be completed to include those records.

- Duration: Include an expiration date for the consent that serves your program purposes or as provided by law.

- Understanding: Be sure the client understands what permission is being granted and how and why information will be shared. If needed, use a translated form and interpreter or read the form aloud. If the client needs more information, provide an additional copy of the DSHS Notice of Privacy Practices or refer the client to the public disclosure officer for your unit

SIGNATURES:

- Client: Have client or a child over age of consent (13 for mental health and drug and alcohol services; 14 for HIV/AIDS and other STDs; any age for birth control and abortions; 18 for health care and other records) sign this box and insert the date of signature. The client may substitute a mark in this box that you witness.

- Agency Contact or Witness: You will sign in this box if you are the one presenting and explaining the form to the client. Please include your telephone number. If the client will be signing the form away from a business site, instruct the client to have a witness sign in this block and provide a telephone number. A notary public may serve as a witness to a client signature.

- Parent or Other Representative: If the client is a child under the age of consent, a parent or guardian must sign. If the child does not meet the age of consent for all records to be shared, both the child and the parent must sign. If the client has been declared legally incompetent, the court appointed guardian must sign and provide a copy of the order of appointment. If someone is signing in another capacity (including a person with a power of attorney or an estate representative), mark "other" and obtain a copy of the legal authority to act. The person signing must date the signature and give a telephone number or contact information.

DSHS 14-012(X) (REV. 02/2003)

SOURCES FOR CONSENT FORMS A COPY OF THIS FORM WILL BE

SENT TO EVERYONE YOU LIST

Please list the name, address and phone number of ANY PROFESSIONALS WHO HA VE SEEN YOU/YOUR CHILD. The sources that you list will be contacted to obtain information regarding you/your child's disability. The back of this form has a list of documentation that is helpful in determining eligibility. Please list anyone who may have the needed information.

A COPY OF THIS FORM WILL BE SENT TO EVERYONE YOU LIST

SCHOOL DISTRICT: Name: P f..oe."'~ Pt... lo /, ·~ Sc. hoo ( S.

Address: 7 W'l Sc.orc-1.u:J 1-fo~ LAl'\L

Phot,f\t)' / A "-L ( "l.. ~ 4 ~

Ok to obtain records from: 0 Phone: ('1-z. ~) c..c i; c. - 1 ~ "l r Fa.~ (I t...3.) 'f 5 ~ - '1>"7 - -PSYCHIATRIST: Name:

Address:

Ok to obtain records from: 0 Phone:

NEUROLOGIST: Name: W'e~cl'/ W1·.-.+er1

MD Address: r 4 C\ s"""'ku....-"' t.Va.j ~ \0

l' \... o e"' 1..,. ' A ?- \ '2- ~'1 s; Ok to obtain records from: 0 Phone: /, t..3) 4 s" - o 1-z. "3

Name: '-

HOSPITAL: Address:

Ok to obtain records from: 0 Phone:

PSYCHOLOGIST: Name: Address:

Ok to obtain records from: 0 Phone:

MENTAL HEALTH Name: S oo.-+-~ wes+ 'B~ \..o.v ~orc:d 1-\t_cd+h

AGENCY: Address: It>\\ Bo"'!. d..-1 P,.\Je....

Pkoe""\'JC A-z... 1-i. 3'1 t;

***see note*** Phone: (1-z..?, ~ Ltc; c,. ~ tf 5 '' FA'f-..: (1-z.;) i.tS(.- 'iSqu For children w o are 13 yrs old or older it is required for the child and the

Ok to obtain records from: D parent to sign the attached CONSENT form.

OTHER: Name: Address:

Ok to obtain records from: D Phone: Rev06/11/2003 ~& ~ Applicant/Legal guardian Signature·~ ~

Attention: Nancy Soderblom

Date: lf/Z?jt6 I

DSHS Notice of Privacy Practices for Client Medical Information

Effective September 23, 2013

DSHS must notify you of your Health Information Portability .and Accountability Act (HIPAA) privacy rights. (45 CFR 164.520). DSHS is a "hybrid entity." Not all of DSHS is covered by HIPAA, only the programs listed as Health Care Components on the DSHS website are covered by HIPAA. This notice only applies to clients served by those covered programs. This notice does not affect your eligibility for DSHS services.

This notice describes how medical information about you may be used and disclosed and how you can get this information. Please review it carefully.

What is PHI? Protected Health Information (PHI) is client medical information held by parts of DSHS covered by HIPAA. PHI is medical information linked to you about your health status or condition, health care you receive, or payment for your health care. DSHS must protect your PHI by law.

What PHI does DSHS have To help us serve you, you may need to give us medical or health information including about me? your location, financial information or medical records. We also may get PHI about you

from other sources needed to serve you or pay for your care.

Who sees my PHI? We see only the smallest amount of PHI we need to do our jobs. We may share PHI with other programs or persons if allowed by law or permitted by you. For example, your PHI may be given to and used by the Health Care Authority and other health care providers to coordinate and pay for your health care. We may share past, current, or future PHI.

What PHI does DSHS share? We only share your PHI that others need to do their job and as allowed by law. You may ask for a list of who has seen your PHI for some purposes.

When does DSHS share PHI? We share PHI on a "need to know basis" to coordinate services and for treatment, payment, and health care operations. For example, we may share information to decide if:

May I see my PHI?

May I change my PHI?

What if someone else needs my PHI?

DSHS 03-387 (REV. 04/2014)

• Medical treatment should be provided.

• We can pay for services by health care providers.

• You are eligible for DSHS programs.

• The care you get from providers meets legal standards.

You may see your PHI. If you ask, you will get a copy of your PHI. DSHS may charge you for copies.

If you think your PHI is wrong, you may ask us to change or add new PHI. You may also ask that we send any changes to others who have copies of your PHI.

You may be asked to sign a form to let us share your PHI if:

• We need your permission to provide services or care;

• You want us to send your PHI to another agency or provider for reasons not allowed by law without your permission;

• You want PHI sent to someone else, such as your attorney, a relative or other representative.

Your permission to share your PHI is good until the end date you put on the form. We can only share the PHI you list. You may cancel or change this permission by writing to DSHS

DSHS Notice of Privacy Practices for Client Medical Information Effective September 23, 2013

May DSHS share my PHI without my permission?

May I put limits on sharing my PHI and how I get it?

What is a breach?

May I have a copy of this notice?

What if PHI privacy practices change?

Who do I contact if I have questions about this notice or my PHI rights?

How do I report a violation of my PHI privacy rights?

DSHS 03-387 (REV. 04/2014)

DSHS may share PHI without your permission in some instances. By law, we may be, required or allowed to share your PHI. Some examples include the need to:

• Report incidents of child or adult abuse or neglect to Child Protective Services, the police or other agencies.

• Provide records under court order.

• Give PHI to other agencies who review DSHS operations.

• Share PHI with agencies that license and inspect medical facilities, such as nursing homes and hospitals.

• Share PHI with service providers or other agencies to take care of you or as needed to determine if you are eligible for services or benefits.

• Give PHI to guardians or parents of minors.

• Use PHI for research.

• Use or disclose PHI in case of emergency or for disaster relief purposes.

You may ask us to limit the use and sharing of your PHI but we do not have to agree. You may also ask that we send your PHI to you in a different format or to a different location.

A breach is the use or disclosure of your PHI that is not permitted under HIPAA, including loss by theft, mistake or hacking. We will notify you by mail if there is a breach of your PHI under HIPAA.

Yes. This notice is yours to keep. If you got this notice electronically, you may ask for a paper copy and we will give one to you.

We are required to comply with this notice. We have the right to change this notice. If the laws or our privacy practices change, we will send you information about the new notice and where to find it or send it to you.

If you have any questions about this notice, you may contact the DSHS Privacy Officer at DSHSPrivacyOfficer@dshs.wa.gov or (360) 902-8278.

If you believe your PHI privacy rights have been violated you can file a complaint with:

The DSHS Privacy Officer, Department of Social and Health Services, PO Box 45115, Olympia WA 98504-5115 or by email to DSHSPrivacyOfficer@dshs.wa.gov. If you file a complaint, DSHS will not change or stop your services and must not retaliate against you.

OR

Submit your complaint online at: https://ocrportal.hhs.gov/ocr/cp/complaint frontpaqe.jsf or by writing to: Office for Civil Rights, US Department of Health and Human Services, 2201 Sixth Avenue - M/S: RX-11, Seattle WA 98121-1831, phone (800) 368-1019. Any complaints to DHHS must be made within 180 days ofthe claimed privacy violation.

liit Vlashlnaron Stn•

Department of Social & Health Seivices

CLIENT NAME

Rosie Sunshine

DSHS NOTICE OF PRIVACY PRACTICES FOR CONFIDENTIAL INFORMATION Effective September 23, 2013

Acknowledgement (Needed when DSHS provides direct health care treatment)

CLIENT DATE OF BIRTH

04/22/2007

I have received a copy of the DSHS Privacy Notice and have had a chance to ask questions about how DSHS will use and share my Personal Health Information.

CLIV,R PERSONAL RE j RESENTATIVE SIGNN!J_RE DATE

lvL-- <;;7' ~ y /t-z.-/16 i7_ ----

/ FOR DSHS USE ONLY

To be completed if unable to obtain signature of client or personal representative.

Describe efforts made to have the client acknowledge receipt of the Notice of Privacy Practices (NPP):

Describe reason why acknowledgement was not obtained:

STAFF MEMBER'S NAME AND TITLE (PLEASE PRINT) I ADMINISTRATION/DIVISION

STAFF'S SIGNATURE DATE

DSHS 03-387 (REV. 04/2014)