(a)  The application for services shall be made through a form provided by the Department of Health and Human Services or an equivalent form.

(b)  When the request is made through a mailed or electronically transmitted request for service(s), the agency shall transfer the information to the application form and maintain the written request in the service record.

(c)  The application form shall include:

(1)           identification of the individual for whom the service(s) is (are) requested;

(2)           identification of the specific service(s) requested for both initial requests and additional requests;

(3)           date of the request;

(4)           signature of the applicant or his/her representative, the date of the signature and for situations where the person making the application executes his/her signature by making a mark (X), the signature of a witness;

(5)           signature of the social worker determining eligibility and date that determination was made; and

(6)           documentation that the application is voluntary and that the individual has been informed of the following rights and responsibilities associated with applications for social services:

(A)          The right to request and obtain a fair hearing if his/her application is not acted on as required by the rules of this Subchapter or if (s)he disagrees with the agency' action in response to his/her application for services;

(B)          the right to confidentiality and that the information given to the agency will be confidential and not released without written consent except for information necessary to establish eligibility, information that may be revealed in the course of agency audits and monitoring and as otherwise required by law; and

(C)          his/her responsibilities to provide accurate and complete information necessary to determine eligibility and, if requested, to provide documentation of such information; to notify the agency within five days of any change in address, employment, income, living arrangement or family size; and that failure to provide accurate and complete information may subject him/her to prosecution.

(d)  The date of the application is when the applicant signs the application, the date of request for guardianship for adults or the date of the report for Adult Protective Services or Children's Protective Services.

(e)  When a signature of the applicant or his/her representative is not obtained because obtaining the signature would create a barrier to the receipt of the service, the social worker shall document the request indicating the service(s) requested, the date of the request and the circumstances that prevented the worker from obtaining the signature.

(f)  In the case of applications for Heath Support Services-Family Planning Component, the signature of the applicant must not be waived.


History Note:        Authority G.S. 143B‑153;

Eff. November 1, 2007;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.