Special Assistance Manual State/County Special Assistance (SA) is a Supplemental Security Income (SSI) state supplement that pays cash benefits to eligible beneficiaries who reside in licensed facilities authorized to receive SA payments. The SA payment is funded by 50% county dollars and 50% state dollars. SA beneficiaries are automatically eligible for Medicaid.

Appendix A Forms

DSS-1473 Request for State Appeal
DSS-1656 Refund Receipt (Collection of Overpayment)
DMA-2041 Third Party Health and Accident Resources Information
DMA-2043 Third Party Liability Accident Information Report
DSS-2216 Request for Record
DSS-3431 Request for Financial Information
DMA-5010 Referral for Inpatient Hospital and Intermediate Care Facilities
DMA-5022 Retroactive Eligibility Checks/ID Cards
DSS-8108 Notice of Benefits
DSS-8109 “Your Application For Benefits Is Being Denied Or Withdrawn”
DSS-8110 “Your Benefits Are Changing” (Timely/Adequate Notice)
DSS-8113 Wage Verification
DSS-8129 Request for Replacement Check and Affidavit
DSS-8176 Contribution Report
DSS-8189 Appointment Notice
DSS-8194 Income Maintenance Transmittal Form
DMA-372-124-ach-ia Adult Care Home FL2 Form
DMA-5001 Notice on the Use of Social Security Numbers
DMA-5049 Referral to Local Social Security Office
DMA-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice
DMA-5094 Notice of Your Right to Apply for Benefits
DMA-5095 Medicaid/Work First Notice of Inquiry
DMA-5097 Request for Information
DMA-5155 Verification of Cash Value of Life Insurance
DMA-5202C Designation of Authorized Representative – Appendix C
DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964
DSS-5023: Direct Deposit Enrollment Authorization Form
DSS-6969: Consent for Release of Information
DSS-8201: County Responsible Overpayment
DSB-2202: DSB/Report of Eye Examination