Fillable St. Johns County Social Services Application (St. Johns County Florida Government)

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St. Johns County Social Services Application (St. Johns County Florida Government)

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The St. Johns County Social Services Application (St. Johns County Florida Government) form is 9 pages long and contains:

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  • 71 check-boxes
  • 192 other fields

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File type: PDF

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200 San Sebastian View, Suite 2300
St. Augustine, FL 32084
P: 904-209-6140 F: 904-209-6141
www.sjcfl.us
St. Johns County Social Services Application
Date: County:
Client’s Name: Sex:
Other names known by:
Phone #: Birthdate:
Address:
Mailing Address:
Email Address:
Who are the members of your household? (adults/children/ages)
Marital Status: Single Married Divorced Annulled Separated Widowed Refused
Race: Native American Asian Black/African American
Native Hawaiian or
Other
Pacific Islander White Refused
Ethnicity: Hispanic/Latino Not Hispanic/Latino Refused
Where did you stay last night?
Do you feel safe in your situation? Yes No
Is there a veteran in your household? Yes No
Next of Kin: Contact #:
Date at Current Address: Date moved to County: Date moved to Florida:
Are you homeless? Y N At risk of homelessness? Y N
Please tell us what we can do to help you today:
Amount of Financial Assistance Requested:
__________Rent _______Deposit(s) ________ Utility _______ Utility Deposit
__________Application Fee
Medical Assistance:
___ Voucher for specialty physician or medical testing ___ Inpatient Hospital Stay
Navigational Services:
___ Assistance applying for Medicaid/Food stamps ___ Housing
___ Food Assistance ___ Community Referrals
___ Resource Center ___ Tokens
___ Cremation ___ Birth Certificates/ID’s
Social Security #:
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How were you referred to our offices? _________________________
Disabling Condition? Yes No Refused
Description of condition: ____________________________________
Do you have a medical problem? ______________________________
How long have you had this problem? _________was it caused by an accident?
Yes No
If yes, explain __________________________________________________________
What is your doctor’s name: ________________
Have you received a monetary settlement in the past five years? If so, what amount?
$______________
Insurance ID # (i.e., Medicare, Medicaid, AARP, BC/BS, AFLAC, etc.)_____________
BENEFIT INFORMATION: Do you have or have you recently applied for any of the
following?
Medicaid - Have you received a denial for Medicaid? _____________
Medicare HMO Group Health Food Stamps
Medicaid Medically Needy/Share of Cost $________
Social Security Retirement Benefits Vocational Rehabilitation Services
Are you a Veteran? YES NO
V/A Benefits - Branch of Service: ________________Dates of Services:__________
Social Security Disability (SSD) Benefits SSI Date ofApplication_____________
Have you ever received a denial for SSD and/or SSI? ___________________________
Are you a U.S. Citizen? YES NO
If NO, you must provide a copy of your Permanent Resident Alien Card.
Date admitted to United States________________ Are you sponsored?
If so, by whom_____________________________________________
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Please provide the following information on all members of your household including yourself:
Household Information **MUST BE COMPLETED IN FULL**
Relationship
DOB
Employer/School
Date
employed
Gross
Monthly
Income
Total Earned
Income
$
If unemployed state
reason:___________________________
______________
Last Place of Employment:______________
Expenses:
Income:
Auto Insurance
Gas - Heating
Unearned Income
Cable
Health Insurance
Child Support
Car
Home Insurance
Unemployment
Childcare
Life Insurance
Workers Compensation
Child Support
Medical Bills
Alimony
Credit Cards
Medication
Social Security (SSI/SSDI)
Electric
Mortgage
Food Stamps
Food
Phone
Furniture
Rent
Other:______________
Gas- Auto
Water
Earned Income Total
Total Expenses
Total Income
Social
Security
Number
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ASSET ASSESMENT SHEET
Do you own/ or are you buying a home YES NO
Amount mortgaged $_________________________________________________
Name of Mortgage Holder _____________________________________________
Do you own or are you buying any other property (house, land, etc.) YES NO
Value $___________ Date Purchased: _____________Balance Owed $___________
Location and Description_________________________________________________
Have you sold any property in the last 2 years? YES NO
If yes, were there any proceeds from sale? __________________________________
Description Current Value Amount Owed Year, Make & Model
1) Car/Truck/Motorcycle $____________ $____________ ______________________________
2) Car/Truck/Motorcycle $____________ $____________ _______________________________
3) Boat/other vehicle $____________ $____________ _______________________________
4) Other vehicles $____________ $____________ ______________________________
Do you or any household member have any of the following:
Bank Name City/State Balance
Checking Account(s) _______ _______________________________________________________
Savings Account(s) ______________________________________________________________
Trust, IRA, CD, Stocks ______________________________________________________________
Money market, bonds ______________________________________________________________
Have you or any household member closed any accounts in the past year?
YES NO
If yes, explain when and why? ____________________________________________
200 San Sebastian View, Suite 2300
St. Augustine, FL 32084
P: 904-209-6140 F: 904-209-6141
www.sjcfl.us
APPLICANT’S STATEMENT
AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT
Chapter 837.06
“Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the
performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable by
imprisonment according to Florida Statute 775.082"
I hereby certify that residence is established in St. Johns County and declare intentions of remaining in
St. Johns County. By signing this form, I am saying that the answers are true and complete to the best of
my knowledge. I know that if wrong information is given or if information is withheld on purpose, I am
breaking the State Law and are subject to the penalties provided by Law, including the penalty for perjury.
Permission is hereby granted and authorized for any insurance company, employer, utility company, or
financial institution to disclose to the Board of County Commissioners and/or its designee, full information
regarding my past, present, or future assets, earnings, and financial status. Privacy rights under State or
Federal Law concerning my income, assets, liabilities or assistance received from such agencies are
hereby waived, and I further consent and request that any State or Federal agency having information
concerning me to disclose same to the Board of County Commissioners of St. Johns County, Florida or its
agents.
I give my permission the release of any medical and/or psychiatric or psychological information to the St
Johns County Social Services Department (SJCSS). I also authorize SJCSS to forward any information
as necessary to hospitals, physicians and/or providers involved in providing my medical care.
I request public assistance since I am unable to pay the usual cost of medical care. I hereby agree that all
hospital insurance, voluntary contributions and part payments will be assigned to the hospital for services.
I hereby authorize the insurance companies to make available to the hospital and/or SJCSS any
requested information concerning medical insurance and financial records related to my medical care.
I do not own any real estate and/or personal property except as written on page 4 of this application.
___________________________________________, do swear or affirm that I am resident(s) of
(Applicant’s Name)
St. Johns County, Florida, and the information given on this application are true and complete. I have
read, or it has been read to me/us, the above statements and I understand the above statements and
releases.
Signature of Applicant:_______________________________________________
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St. Johns County Social Services
ACCESS Florida Assisted Service Site Release
I, ____________________________________, understand that by my signature I am authorizing the
Department of Children and Families (DCF) to release limited case information to
______________________________________, a representative of St Johns County Social Services. This
release is made to St Johns County Social Services in their role as a DCF Assisted Service Site with
Customer look up and shall be used solely to fulfill their obligation in assisting me with the application
filed with DCF or the application that I previously filed with DCF. Information to be released is limited to:
• Status of Application (approved, denied, enrolled or pending)
• Reason for closure or denial
• Scheduled interview dates and times
• Verification requested and dates due
• Other: ____________________________________________
No additional information shall be provided to the DCF Assisted Service Site without my specific written
consent. This authorization expires ninety (90) days following the date signed.
Signature: ________________________________ Date: ___________________________
Date of Birth: _____________________________ Last 4 digits of SSN: _______________
Yo, _____________________________________, comprendo que al firmar le doy autorizacion al
Departmento de Ninos y familias (DCF) que compartan informacion limitada sobre el caso a
__________________________________ un representante de St Johns County Social Services. Esta
liberacion es para St Johns County Social Services que representa al DCF Sitio de Servicios con asistencia
para clientes, y sera usada solamente para las obligaciones en asistirme con la solicitud archivada con DCF.
Informacion que sera compartida es limitada a:
• El estado de la aplicacion (aprovada, rechazada, registrada o pendiente)
• Razon de cierre o rechazo
• Fecha y horario de entrevista
• Solicitar verificacion y fecha de vencimiento
No se dara informacion adicional al DCF Sitio de Servicios con asistencia para clientes, sin un
consentimiento escrito por mi. Esta autorizacion se vencera en 90 dias del dia que lo firmo.
Firma: __________________________________ Fecha: ___________________________
Fecha de nacimiento: _____________________ Ultimo 4 digitos de SSN: ____________
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Authorization for Release of
General and/or Confidential Information
All information is accurate to the best of my knowledge. This Agency may verify
information contained in this application, including the Florida Power & Light Company
Electric account for which I am seeking assistance.
I, _____________________________, hereby authorize FPL and this Agency to release
pertinent information to related community agencies. I understand that the need or
purpose for this disclosure is solely to assist in alleviating the current situation.
CLIENT’S SIGNATURE: _______________________________________________
DATE: ___________________
** The client must sign this application to receive financial aid as it pertains to their
FPL electric account.
CASE MANAGER’S SIGNATURE: ________________________________________
DATE: _____________________
AGENCY NAME:_______________________________________________________
ADDRESS: ___________________________________________________________
TELEPHONE # ________________________
The client has the right to appeal the decision of this Authorization for Release of General and/or
Confidential Information application by requesting to speak with the Agency Director, or whomever this
Agency deems necessary.
The Au
thorization for Release form should be maintained by the Agency in the applicant’s case file.
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Care Connect Information Network
ServicePoint Consent
Release of Information (ROI)
Purpose of this form: St. Johns County Health and Human Services is a participating provider of vital services (“Participant”)
who is active ServicePoint, a project of the Care Connect Information Network (CCIN) hosted by St. Johns Care Connect, Inc.
ServicePoint participating agencies work together to provide services to persons and families in need. When you request or receive
services, we may collect data about you and your household such as:
Your name, date of birth, Social Security Number, gender, ethnicity, race, veteran status, prior residence and program status.
Your service needs, income, benefits, education, employment, destination, disability, general health, as well as pregnancy,
HIV/AIDS, behavioral health, legal, and domestic violence status, destination.
How will my data be used? The ways in which the Agency may use or disclose your information are discussed in our Notice of
Privacy Practices, which is posted in our reception area; we can direct you to the Notice at your convenience.
How will my data be protected? We enter your data in a computer program that is protected by passwords and encryption
technology. Each Participant and ServicePoint user must sign an agreement to maintain the security and confidentiality of the
information. Any person or Participant that violates the agreement may lose their access rights and be subject to further penalties.
How do I benefit by providing the requested information and sharing it with other agencies? By sharing your information with
other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to t ell
your “story.” You also help agencies document the need for services and demonstrate that funding is needed.
PLEASE PRINT NAME OF INDIVIDUAL AFFECTED BY THIS ROI:
Client Informed Consent/Authorization for Release of Information - By signing this form, I agree that the Agency may disclose
and other participating agencies in the SERVICEPOINT may use the following information for lawful purposes of the agencies that
participate in the SERVICEPOINT and their employees and agents: (please initial & check the applicable boxes if appropriate)
1) I agree to share all of my information with other SERVICEPOINT participating agencies.
2) I agree to share all of my information with other SERVICEPOINT participating agencies, WITH THE
EXCEPTION OF: (Check All That Apply)
□
HIV/AIDS Information, such as status, diagnostic test results, mode of transmission, sexuality
□
Domestic Violence Information, such as abuse history, abuser information, trauma information
□
Behavioral Health Information, such as substance and alcohol abuse and mental illness information
3) I DO NOT agree to share any of my information with other CCIN participating agencies.
I UNDERSTAND THAT:
I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will
not be affected. I may also request a copy of this consent after I sign it.
This consent form expires in seven (7) years. I have the right to revoke this consent at any time by writing to the Agency, except
to the extent that the agency has acted in reliance on it. Past information I previously consented to release will not be retrieved
from agencies that received that information. I understand that my revocation must be in writing.
The Agency has posted a Notice of Privacy Practices, and I may request a paper copy of the Notice from the Agency. I
acknowledge that I have been given an opportunity to read and/or request a copy of the Notice and that I have read the Notice.
The Notice describes ways in which my personal information may be used and disclosed within and outside of the Agency. Its
terms may change and I may obtain a copy of the Notice by writing to: CCIN SERVICEPOINT c/o St. Johns Care Connect, 400
Health Park Blvd., St. Augustine, FL 32086.
I understand that neither the Agency, nor the CCIN, can control how another Participant will use or disclose my information that it
receives under this consent. It is possible that the other agency will disclose my information to others, and that the disclosed
information may no longer be protected by federal privacy regulations.
Signature of Individual or Guardian Date Signature of Witness Date
A SEPARATE ROI WILL BE FILLED IN FOR DEPENDANTS IN THE CASE OF A HOUSEHOLD SITUATION.
NO PERSONAL DATA WILL BE COLLECTED UNLESS THIS ROI IS ACKNOWLEDGED AND SIGNED.
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NOTICE OF PRIVACY PRACTICE
The Social Services Notice of Privacy Practices have been explained to
me. I have received the Social Services Notice of Privacy practice covering
the Social Services’ policies on disclosure of Protected Health Information.
____________________________________________________________
Client Signature Date
____________________________________________________________
Case Specialist Signature Date
200 San Sebastian View, Suite 2300
St. Augustine, FL 32084
P: 904-209-6140 F: 904-209-6141
www.sjcfl.us
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SOCIAL SERVICES- NOTICE OF PRIVACY PRACTICES
This notice describes how health information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
I. We have a legal duty to safeguard your protected health information (PHI).
We are legally required to protect the privacy of your health information. We call this information
“protected health information”, or “PHI” for short. It includes information that identifies you and
that has been created or received by us about (1) your past, present, or future health or condition(s);
(2) the provision of health care to you; or (3) the payment for this health care.
We are providing you with this notice about our privacy practices that explains how, when, and why
we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your
PHI than is necessary to accomplish the purpose of the use or disclosure.
We are legally required to follow the privacy practices that are described in this notice. However, we
reserve the right to change the terms of this notice and our privacy policy at any time. Any changes
will apply to the PHI we already have. If we make an important change to our policies, we
will promptly change this notice, post a new notice in the main lobby area of the program, and
have copies available for distribution.
You can request a copy of this notice from the Social Services Division at any time.
Note to parents/guardians: If you reading this notice as your child’s personal representative, this
notices describes our privacy practices with respect to your child. Please let us know if you have
any questions.
II. How we may use and disclose your PHI.
We use and disclose PHI for many different reasons. For some of these uses or disclosures, we
need your specific authorization, while for others, we do not. Below, we describe the different
categories of our uses and disclosures.
A. We may use and disclose PHI for the following reasons without a written authorization.
1. For treatment, payment, or health care operations.
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a. For treatment. We may disclose your PHI to physicians, nurses, mental health
professionals, and other health care personnel who provide you with health care
services or are involved in your care. For example, we may disclose your PHI to your
primary care physician for treatment purposes.
b. To obtain payment for treatment. We may use and disclose your PHI in order to bill
and collect payment for the treatment and service provided to you. For example, if a
service we provide is billable to a third party insurance company or to Medicaid, we
may submit the information to them that is necessary for payment.
c. For health care operations. We may disclose your PHI in order to operate our
program. For example, we use your PHI to evaluate the quality of the health
care services you received.
2. When a disclosure is required by law. For example, we are required to make disclosures
about victims of abuse, neglect, or domestic violence to the appropriate agency.
3. For public health activities. For example, we are required to report information pertaining
to certain diseases to local health authorities.
4. For health oversight activities. For example, we will provide the necessary information to
assist a government agency conducting an investigation or inspection of our health care
activities.
5. To avert a serious threat to health or safety. For example, we may disclose PHI if in good
faith we believe it is necessary to prevent or lessen a serious and imminent threat to the
health or safety of a person or the public.
6. For specific government purposes. For example, we may disclose PHI if we believe it is a
matter of national security.
B. Other uses and disclosures of your PHI not listed above, and permitted by the laws that apply us,
will be made only with your written authorization. If you choose to sign an authorization to
disclose your PHI, you may revoke (i.e., take back) it in writing at any time, except to the extent
that we have already taken action based on the original authorization.
III. You have the following rights with respect to your PHI:
a. The right to request limits on uses and disclosures of your PHI. We are not required,
however, to agree or comply with your request.
b. The right to choose how we send PHI to you. You have the right to ask that we send
information to you to an alternate address (e.g., your work address rather than
your home address) or by alternate means (e.g., email instead of regular mail). We
must agree to your request so long as we can easily provide it in the format you
requested.
c. The right to see your PHI. In most cases you also have the right to look at or get copies
of your PHI that we have, but your request must be made in writing. If we don’t
have your PHI, but know who does, we will tell you how to get it. We will respond
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to you within 30 days after receiving your written request. In certain cases, we may
deny your request. If we do, we will tell you, in writing, our reasons for the denial and
explain your right to have the denial reviewed. Instead of providing the PHI you
requested, we may provide you with a summary or explanation of the PHI as long as you
agree to that in advance.
d. The right to correct or update your PHI. If you believe that there is a mistake in your PHI,
or that a piece of important information is missing, you have the right to request that
we correct the existing information or add the missing information. You must provide
the request and your reason for the request in writing. We will respond within 60 days
of receiving your request. If we approve your request, we will make the change to your
PHI, tell you that we have done so, and tell others that need to know about the change.
We may deny your request in writing if the PHI is (i) correct and complete, (ii) not
created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written
denial will state the reasons for the denial and explain your right to file a written
statement of disagreement. If you don’t file a written statement of disagreement, you
may alternatively ask that your original request and our denial be attached to all
future disclosures of your PHI.
e. The right to receive notification if and when your PHI is breached. A breach is when
there is an unauthorized acquisition, access, use or disclosure of PHI which
compromises the security or privacy of this information.
f. The right to get a list of the disclosures we have made. You have the right to get a list
of those instances in which we have disclosed your PHI. The list will not include uses
or disclosures made to you; those related to treatment, payment, or health care
operations; those that were authorized by you; those made for national security
purposes; or in certain circumstances, those made to correctional institutions or for
other law enforcement custodial situations.
g. Your request must be made in writing and you must specify the time period for which
you want to receive a list of disclosures. This time period may not be longer than six
years and may not include dates prior to July 1, 2003. We will respond within 60 days
of receiving your request. The list we will give you will include the date of the disclosure,
to whom the PHI was disclosed (including the address if known), a brief description of
the PHI disclosed, and a brief statement of the reason for the disclosure.
h. The right to get this notice by email. You have the right to get a copy of this notice
by email. Even if you have agreed to receive the notice via email, you also have the
right to request a paper copy of this notice.
IV. How to express concerns about our privacy practices.
If you think that we may have violated your privacy rights, or you disagree with a decision we made
about access to your PHI, you may file a complaint with the person listed in Section V below. You
also may send a written complaint to the Secretary of the Department of Health and Human
Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. We will take no retaliatory
action against you if you file a complaint about our privacy practices.
V. Contact information about this notice.
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If you have any questions about this notice or any complaints about our privacy practices, or would
like to know how to file a complaint with the Secretary of the Department of Health and Human
Services, please contact our offices at (904) 209-6080 or by traditional mail at 200 San Sebastian
View, Ste. 2300, Saint Augustine, FL 32084. An administrative employee will assist you in this matter.
VI. Effective date of this notice
This notice is effective as of July 1, 2003. It was last updated May 6, 2016
Application and document submission instructions on last page.
______________________________________________________________________________________________
Required Documentation
The following completed application and documents are required to process your request. You
will need Acrobat Reader or a similar PDF viewer to view application and/or fill out.
1. Completed St. Johns County Social Services Application (PDF)
2. Documented hardship: some examples are loss of employment, reduction in hours or
hospital stay
3. St Johns County Picture ID or Driver’s License
4. Social Security card for all members of household
5. Proof of income for last 30 days
6. Bank statements for last 30 days
7. Past due utility bill
8. 3 day notice or letter from landlord stating the amount due with description of what the
total covers and copy of full lease.
Application & Document Submission Instructions
Complete entire application and submit ALL of the required documents at the same time. All
required documentation must be provided for staff to start the eligibility for assistance process.
If you have any questions, please call (904) 209-6140.
Document Submission – Completed application and documents can be submitted through one
of the following options:
• Submit electronically using our SJC Document Uploader | Uploader Instructions (PDF)
• Print out and drop off in a locked box outside our door.
• Print and mail to: Social Services, 200 San Sebastian View, Suite 2300, St. Augustine, FL
32084.
Contact Us
Have questions or need assistance? We are open to assist you! Please call (904) 209-6140.
• Social Services Main Office – Monday thru Friday, 8am to 5pm
• Social Services Hastings Office – Tuesday & Thursday, 10am to 5pm
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St. Johns County Social Services Application (St. Johns County Florida Government)

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