Section 148-50-4 - PROCEDURESA. The Custodian must contact the Bureau of Child and Family Services to request an application for the "Section 4004-A " Voluntary Agreement program.B. The Custodian must complete the application and return it to the Bureau of Child and Family Services along with the following: 1. A certified copy of the child's birth certificate;2. The child's social security number,3. A copy of the most recent Pupil Evaluation Team recommendation, if applicable;4. Copies of all psychological evaluations and testing results, discharge summaries from psychiatric hospitals, a family psycho-social evaluation and signed releases of information for all previous and current health and mental health providers;5. A copy of the child's Medicaid card, if any;6. The name, address and telephone number of the Bureau of Children with Special Needs case manager, if applicable;7. A list of community providers' names, addresses and telephone numbers the services provided, and the dates that services were received;8. Copies of decisions of any denial of services from providers;9. Copy of the parents' state income tax returns for the past two years;10. Copy of any child support order currently in effect;11. Documentation of private insurance if covered and signed Third Party Resource Information Request, Form Number SWMA 004 R.C. in cases where the eligibility criteria have been met but treatment services are unavailable, the Bureau of Child and Family Services will review the completed application to determine if it meets the eligibility criteria in Section III. D. The applications which meet the, eligibility criteria in Section III and for which the Department has available, funds and treatment resources, will be referred to the regional BCFS office which covers the area where the family lives. A regional supervisor may refer that case to the central or regional interdisciplinary team to help in development of a service plan.E. Applicants who do not meet the eligibility criteria will be notified of the decision in writing within 45 days of receiving the, completed application. All required attachments noted in Section TV. B. (1 -1 1) will be returned to the applicant.F. The Bureau of Child and Family Services will determine, based on the Child Support Worksheet DCCV - 50/CV - 4 [7/901 and the Child Support Affidavit DCCV 51-CV - 5 [6193] used by the District Courts in child support orders, the amount of financial contribution to be required of the Custodian. In situations where the, court has already issued a child support order, copies of previously completed forms may be submitted if they remain accurate.G. The Custodian must pay to the, Department of Human Services, the amount determined in Section IV.F. H. When the Custodian, or non-custodial parent has private insurance,, this must be utilized for the costs of services provided.I. When there is court ordered child-support, the funds awarded for the child for whom the Voluntary Agreement is sought must be used to fund services sought through the Voluntary Agreement. When the child is eligible for benefits through Supplemental Security Income, Disability, the Veterans Administration, Social Security, or other Federal financial sources, these funds must be used to fund services sought through the Voluntary Agreement.
K. The approved Voluntary Agreement will be signed by the Commissioner of the Department or his/her designee and the Custodian. The 180 days will begin on the date this agreement is signed.L. Within 10 days of the signing of the Voluntary Agreement the Department of Human Services will file a petition for a court finding according to 22 M.R.S.A.4004-A(2).10-148 C.M.R. ch. 50, § 4