Effective Date: 
10/1992

Documents

Instructions

Updated: 9/2004

Purpose

To request and share case information not available through data inquiry.

Form 2067 is used by staff in TANF, Food Stamps, Medicaid, self-support services, protective services, and community care for the aged and disabled.

Procedure

When to Prepare

Prepare Form 2067 when

  1. eligibility staff request or share information about case record transfers. When the client reports a move to the losing office, list in “Comments” the known reporting and verification requirements the client must complete at the gaining office in order to continue receiving benefits. (B-500)
  2. eligibility staff request or share other case information. Example: An advisor notifies another eligibility worker with an associated case that TANF benefits have been granted, denied, or adjusted.
  3. DADS staff and/or contractors in different program areas share information or request or refer services. Examples:
    • TANF/Medicaid staff refer a client to child care, Family Health Services nurse, THSteps, family planning, or genetic services;
    • community care for the aged and disabled and Medicaid eligibility staff report information about a client or request information about a client; or
    • protective services staff notify an eligibility advisor that a
      • protective payee is being named for a TANF caretaker, or
      • child has been removed from a TANF/Medicaid home.

Number of Copies

Complete an original and two copies.

Transmittal

Send the original to staff whom you are providing information. When requesting information, send the original and one copy. When responding to a request for information, return the original to staff who requested the information. Place the copy in a suspense file or case folder as appropriate.

For eligibility case record transfers, give the original to the client when the household reports a move to the losing office.

Form Retention

Food stamp case folder copies are kept for three years from the date on the form. They are filed under correspondence. Other program copies may be destroyed when no longer needed.

Detailed Instructions

Enter names and addresses of the staff receiving and sending Form 2067. Enter the case name and address. Enter category or kind of assistance and the case or other identifying number.

Check the appropriate blocks to show what kind of information is being shared or requested or which services are requested.

Enter a description of the information being shared or requested. Use the back of the form if needed.

Enter the initiating staff’s phone number, signature, and date.

Response

Enter a description of the information; use the back of the form if needed. Enter the responding staff’s phone number, signature, and date. Enter the name and addresses of the people receiving and sending the response.

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