Original Issue Date - If applicable, the issue date of the issuance used to purchase food reported as destroyed.Įnsure that the month shown in the identifying information at the top of the form and the month shown in the lower section are the same when providing replacement benefits. Old Address - Enter the client's old address, if different from the current address.īenefit Month and Year and Allotment Amount - The month and year for which the benefit was issued and the amount of the allotment. Enter the household’s SNAP case number.Ĭurrent Address - Enter the household's current mailing address.Ĭomplete the following when replacing benefits:ĭate Reported - Enter the date the client requested the replacement.ĭate Received - Enter the date HHSC received the signed form. AR completes the interview for the applicant.Ĭase Name - Enter the name of the head of the household as listed in the case record.Ĭase No. Follow the step-by-step instructions below to design your simplified report online: Select the document you want to sign and click Upload. The Indiana Professionals Recovery Program (IPRP) is a monitoring program for healthcare professionals, such as nurses or pharmacists, who are currently struggling with drug or alcohol addiction.YOU MUST: - ANSWER ALL QUESTIONS ON THIS FORM (USE ADDITIONAL. has difficultly with the distance to the HHSC office andĪllow the AR to sign Form H1855 only if the: Your Supplemental Nutrition Assistance Program (SNAP) benefits will end unless you recertify.The local HHSC office mails Form H1855 only for a person who: mail the form to the person with a postage paid return envelope or.allow the AR to take the form to the person and return it to HHSC.We must follow the SNAP rules for processing your application. If the person cannot to come to the HHSC office to complete Form H1855, staff must: Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (833) 620-1071. Ensure that the person reads the form and understands what they are signing. The head of the household, spouse, responsible household member or authorized representative (AR) must sign Form H1855. Staff complete Form H1855 per information supplied by the household. Save a copy in the electronic case record. issuing priority benefits when TIERS is unavailable.replacing food purchased with SNAP benefits that were reported destroyed or.To provide a record of a person's statement for use if HHSC discovers perjury or an intentional program violation. had food destroyed that was purchased with SNAP benefits. (2) Indiana State Nurses Assistance Program or ISNAP means an abstinence based program for the rehabilitation and monitoring of: (A) impaired registered nurses or (B) licensed practical nurses that have been affected by the personal use or abuse of alcohol or other drugs.has not previously received benefits in that month or.To obtain a written statement from an applicant or recipient that the household: Medicaid Supplemental Payment & Directed Payment Programs.
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