• Money Management Client Referral

    All information entered and submitted is HIPAA-compliant
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  • Referral Type

  • The Social Security Administration requires that we submit two forms in our application to be selected as Rep. Payee:

    SSA-787: to be completed by a physician who has recently examined the client. Clinician must indicate that the feel a Rep Payee is necessary on pages 2 and 3

    SSA-787 - Medical Source Opinion of Patient's Capability to Manage Benefits

    SSA-827: authorization to disclose information to SSA, to be signed by client

    SSA-827 - Authorization to Disclose Information to SSA

    In order to expedite our application, please complete these forms and use the upload button below to submit with this referral.

  • Upload Documents
    Cancelof
  • Client Communication

  • Referral Source

  • Current Protective Arrangements

  • Client Income

  • Monthly income source(s) and amount(s)
    SSA *
    SSI *
    SSDI *  
    MA SSP  *    
    Other   *   

  • Client Personal Information

  • Birthplace: * * *  
  • Living Information

  • Medical Coverage

  • Client Status

  • Should be Empty: