HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE
HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Client Information Name: Address: City:_______________State:__________Zip: _______City & State born in: ______________ Daytime Phone #: ____________________ Cell#: __________________________________ Social Security#:__________________________________ DOB:____________________ Mother's Maiden Name:____________________________Race:______ Marital Status:__________ Do you live alone? Yes No If no, whom do you live with? NAME RELATIONSHIP NAME RELATIONSHIP NAME RELATIONSHIP Medicaid/Medicare#:__________________________________________ Does Client Receive Food stamps?: _______________ Amount:__________________________ Referring Agency:_________________________________________________________ Agency Address:______________________________________________________________ Social Worker/Case Manager:____________________________________________________ Phone:__________________________________Ext:_______Email:______________________ Emergency Contact/Next of Kin:__________________________________________________ Address:____________________________________________________________________ Phone:___________________________________ Relationship:_________________________ HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Questionnaire 1) Has this client previously received services from a Representative Payee? If No and *If client is currently his/her own payee, a SSA-787 must be signed by an MD indicating why the client needs a payee. In lieu of a doctor’s statement, the testimony of 3 persons familiar with the client’s situation can be submitted as evidence as to why the client needs a payee. Yes No _______________________________________________________ _________________________________________________________________________ 2) What is the Clients disability? _________________________________________________ 3) Does the Client have family members or friends available to provide this type of service? Yes No ___________________________________________________________ 4)Does the Client have a Court appointed legal guardian ? If yes provide name, address and contact information. Yes No ____________________________________________________ ____________________________________________________________________________ 5)Explain why the HJP Payee Services are required at this time: ________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Client Name:____________________________________________________ Date:____________ Signature:_______________________________________________________Date:___________ Payee Representative:_____________________________________________Date:____________ HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Consent to Release Information To: H. J. Pearl Solution Representative Payee Services: Name: ______________________________________________________________ DOB: ___________________________________ Social Security:_______________________________ I hereby give my consent to H.J. Pearl Solution Services/HJPSS to obtain and/or exchange information for the purpose of either planning for my well-being and/or assuring my continuing eligibility for Social Security benefits. I also hereby give my consent to HJPSS to obtain and/or exchange information regarding the item(s) below for the purpose of planning for my well-being. Social Security Number Account Ledger Current Monthly SSA/SSI Bank Account Burial Trust Medi-Cal Wages/Employment Record Social History Utility Bills Address/Living Arrangements Other (explain below) I am the individual, to whom the requested information/records applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare that I have examined all of the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that HJPSS is not responsible if a person authorized to obtain information regarding my account does so with false pretenses and HJPSS is not responsible for any effect to your benefits caused by releasing the requested information. Signature of Claimant/Legal Guardian: ______________________________________________ Date: __________________________ HJPSS. Staff Member: ___________________________________________________________ Date:___________________________ HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Budget Worksheet Client Name: SSI (T16): SSN / TRUST: SSA (T2): Effective Date: OTHER: Monthly Budget Amount: _$________________ TYPE AMOUNT DATE / FREQUENCY VENDOR NAME & ADDRESS Rent P&I Electricity GAS Medical Other/Misc Payee Fee TOTAL:________________________________________________________ ______________________________________________________________ ______________________________________________________________ HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE SERVICES APPLICATION Representative Payee Acknowledgement I, ______________________________________________________ understand that by signing and submitting these documents, that H.J. Pearl Solution Payee Services that my bank account will not be used as a personal account. I am therefore not authorized to make any deposits or withdrawals without consent of HJPSS. If a debit is required electronically or otherwise, it will be reviewed and authorized. An addendum will be made to the current budget for the following month. Client Signature: ______________________________________Date:__________________ HJPSS Rep: __________________________________________Date: __________________ HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Client/Organization Rights and Responsibilities Client Rights: Right to treated with dignity and respect Right to receive services regardless of sex, age, race, religion, sexual preference, marital status, national origin, veteran status or handicap. Right to accept or decline the service of HJPSS. Right to participate in developing and revising the planned budget and the services received in order to meet specific needs and promote independence. Right to receive information concerning available community resources Right to evaluate the services provided, voice grievances, ask questions and offer suggestions without fear of negative impact on the services provided. HJPSS office hours are Monday thru Friday from 9:00am to 5:00pm by appointment only. Office is closed on the weekend and holidays. Client Responsibilities Responsibility to provide an accurate financial history and status Responsibility to communicate to agency personnel any changes in financial status, living arrangements, securing or leaving employment, rent increases, or supportive services Responsibility to follow your budget Responsibility to treat HJPSS personnel with dignity, courtesy and respect Responsibility to provide accurate financial information and to pay for services as provided for in the Service Agreement Responsibility to maintain an adequate and safe environment for the delivery of service Responsibility to provide receipts for all special checks Responsibility to schedule appointment times with payees as drop-ins are not able to be accommodated I agree as a client of H. J Pearl Solution Services, to act on my behalf regarding my finances. I give permission to release any information to HJPSS to other agencies that HJPSS will operate as a advocate for the benefit. Client: ___________________________________________________ Date:_________ Representative Payee: _______________________________________Date:_________ P.O. Box 7792 Macon, GA 31206 404-721-8115 HJ PEARL SOLUTION SERVICES REPRESENTATIVE PAYEE APPLICATION Intake Date: ___________________________________________________________ Client Name: ___________________________________________________________ Checklist: FOOD HOUSING CLOTHING TRANSPORTAION MEDICAL BANK Comments:________________________________________________________ _________________________________________________________________ ___________________ ________________________________________________________________ ______________________________________________ Representative Payee:______________________________________________ Date:______________________________________ H J Pearl Solution Payee Services AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient’s Name: Date of Birth: Previous Name: Social Security #: I request and authorize release healthcare information of the patient named above to: to Name: Address: City: State: Zip Code: This request and authorization applies to: Healthcare information relating to the following treatment, condition, or dates: All healthcare information Other: The above healthcare provider is authorized to discuss my medical treatment and health information with H J Pearl Solution Services, which is acting on my behalf regarding my medical concerns. The client information is to be used in pursuant of client financial management. Medical Release may include: billing statements, notes, memoranda, correspondence, claim forms, reports and insurance documents regarding services. • I have the right to revoke this release authorization at any time in writing to HJPSS • This authorization will expire upon termination of representation by HJPSS. • I have the right to copies of the information being released and disclosed. Yes No I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. Yes No I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Patient Signature: Date Signed: Representative Payee:___________________________________________________ Date Signed: ______________ Progress Notes Client:__________________________________________________________________ Date Initials H J Pearl Solution Representative Payee Services We help you, make your money make sense.... P.O. Box 7792 Macon, GA 31209 404-721-8115 Hours: Regular Hours Monday - Thu 9:00 am - 4:00 pm Friday 9:00 am - 6:00 pm Saturday 9:00 am - 12:00 pm Suntrust-- Branch Locations-- Cherokee Office 1095 Pio Nono Ave Macon, GA 31204 (478) 751-5791 SunTrust Bank 125 S Houston Lake Rd Macon, GA 31210 (478) 741-2265 Suntrust-- Branch Locations-- Galleria Office-- Saturday Banking Atm 125 S Houston Lake Rd Warner Robins, GA 31088 (478) 953-3302 SunTrust Bank 621 Russell Pkwy Macon, GA 31210 (478) 741-2265 .SunTrust Bank 195 Tom Hill Sr Blvd Macon, GA 31210 (478) 757-2701 SunTrust Bank 3201 Vineville Ave Macon, GA 31204 (478) 757-5571 SunTrust Bank 3625 Pio Nono Ave Macon, GA 31206 (478) 741-2265 SunTrust Bank 2998 Riverside Dr Macon, GA 31204 (478) 741-2265 SunTrust Bank 5928 Zebulon Rd Macon, GA 31210 (478) 741-2265 SunTrust Bank 4290 Hartley Bridge Rd Macon, GA 31216 (478) 741-2265 SunTrust Bank Macon, GA 31201 (478) 745-2821 SunTrust Bank 125 S Houston Lake Rd Warner Robins, GA 3108 (478) 953-3302 SunTrust Bank 319 Margie Dr Warner Robins, GA 31088 (478) 971-2080 SunTrust Bank 750 Macon St Bldg 911Warner Robins, GA 31098 (478) 329-5711 SunTrust Bank 750 Macon St Bldg 911Warner Robins, GA 31098 (478) 329-5711 SunTrust Mortgage 1903 Watson Blvd Warner Robins, GA 31093 (478) 3285080 SunTrust Bank 207 Russell Pkwy Warner Robins, GA 31088 (478) 3295790 SunTrust Bank 3600 Mercer University Dr Macon, GA 31204 (478) 7412265 1903 Watson Blvd Warner Robins, GA 31093 (478) 9222268 SunTrust Bank 606 Cherry St Macon, GA 31201 (478) 755-5133 SunTrust Mortgage 125 S Houston Lake Rd Warner Robins, GA 31088 (478) 953-3705 SunTrust Bank 614 Cherry St Macon, GA 31201(478) 755-5282 606 Cherry St Macon, GA 31201 (478) 755-5285 SunTrust Bank 872 GA Highway 96Warner Robins, GA 31088 (478) 9885500 SunTrust Bank 577 Mulberry S t Macon, GA 31201 (478) 741-2265 SunTrust Bank 80 Cohen Walker Dr Warner Robins, GA 31088 (478) 2187796 SunTrust Bank 1104 Gray Hwy Macon, GA 31211(478) 751-5813 SunTrust Mortgage 5928 Zebulon Rd Macon, GA 31210 (478) 757-2708 SunTrust Mortgage 4290 Hartley Bridge Rd Macon, GA 31216 (478) 784-5632 SunTrust Bank 2501 N Columbia St Milledgeville, GA 31061 (478) 4541000 Social Security Office Hours Social Security Office for Macon, GA 31210 Macon Social Security Office Address : 3530 RIVERSIDE DRIVE MACON, GA 31210 Social Security Phone (Local) : 1-888-759-3917 Social Security Phone (Nat'l) : 1-800-7721213 TTY : 1-478-476-9342 Social Security Office for Milledgeville, GA 31061 Milledgeville Social Security Office Address : 109 CYPRESS CORNERS MILLEDGEVILLE, GA 31061 Social Security Phone (Local) : 1-866-348-5817 Social Security Phone (Nat'l) : 1-800-7721213 TTY : 1-478-453-1101 Social Security Office for Warner Robins, GA 31099 Warner Robins Social Security Office Address : 220 CARL VINSON PKWY WARNER ROBINS, GA 31088 Social Security Phone (Local) : 1-866-931-7084 Social Security Phone (Nat'l) : 1-800-7721213 TTY : 1-478-922-8548 Social Security Office Hours MON: 09:00 AM - 03:00 PM TUES: 09:00 AM - 03:00 PM WED: 09:00 AM - 12:00 PM THUR: 09:00 AM - 03:00 PM FRI: 09:00 AM - 03:00 PM SAT & SUN: CLOSED Medical Information Form Last Name First Name Middle Initial Date of Birth Weight Blood Type Address Race City State Primary Insurance Company Secondary Insurance Company Primary Insurance Numbers & Group Allergies None Unknown Medical Allergies: ____________________ _____________________ _____________________ Zip Code Secondary Insurance Numbers & Group Cardiac None Unknown Angina Arrhythmia Cardomythopathy CHF Congenital Implant Defibrillator Other:_________________ Surgery None Unknown Abdominal Heart Lung Neurological Other___________ ________________ Psychological Seizures Substance Abuse TB Unknown Other______________ Chronic Illness None Asthma Bleeding Cancer COPD Diabetic Other_________ Dialysis/Renal Gastrointestinal Headaches Hepatitis HIV Positive Hypertension Paralysis Current Medications (circle) None Unknown____________________________________________________________________ ___________________________________________________________________________ Emergency Contact Information Primary Physician Phone Number Primary Contact Name & Relationship Phone Number
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