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  • Money Management Client Referral

    All information entered and submitted is HIPAA-compliant

  • Thank you for your interest in submitting a referral to our Money Management program! The Money Management Program includes two service options -- the Bill Payer and Representative Payee programs.

    The Bill Payer program is structured to assist individuals who have capacity to participate in financial and bill-paying tasks, but benefit from a volunteer's support with initiating actual payments, reading and understanding bills, budgeting, etc. Bill payer clients retain control of their financial affairs and all decision making.

    The Representative Payee program is intended to support individuals who lack capacity to engage with their finances at a sufficient level to work with a volunteer, and/or may be unsuitable for a volunteer match to due to behavioral, mental health, or other challenges.

    Before completing the referral, we ask that you answer the following Yes/No questions to help determine what level of support will most benefit the individual.

  • Please note, the Money Management Program does not provide the following:

    • Assist with tax preparation or filing.
    • Provide investment advice.
    • Run errands or drive individuals to appointments.
    • Provide money or loans to individuals.
    • Complete public benefits or housing applications.
    • Act as intermediary in family financial conflicts.

  • Based on your responses to these questions, it is likely that the individual may not be eligible for the Bill Payer program and might benefit more from Representative Payee support.

    If it is your and/or the individual's intent to make a referral for the Bill Payer program, we encourage you to contact Teddy Lewis (teddy.lewis@@eldercare.org) to review options before taking the time to complete a full referral on the next page.

    If you wish to make Representative Payee referral, please proceed to the next page.

  • Based on your responses to these first questions, it is likely that the individual could be eligible for either the Bill Payer or Representative Payee programs.

    Please proceed to the next page to complete a full referral.

     

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  • Referral Type

  • The Social Security Administration requires that we submit three forms in our application to be selected as Rep Payee. In order to expedite our application, please complete these forms and use the upload button below to submit with this referral.

    • 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

    • SSA-4164: to be signed by client, confirming that they are agreeable to having SCES servce as Rep Payee

    SSA-4164 - Advance Notification of Representative Payment

     

  • 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

  • Beneficiary

    To whom should we remit funds in the event of the consumer's passing?
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  • Medical Coverage

  • Client Status

  • Should be Empty: