Selfservice controller

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Selfservice controller

  1. 1. **Keep in mind that you do not need to mail this print-out to your local agency.**Thank you for using COMPASS to apply for benefits!Mark Ostrander, your application has been submitted to Online Services on June 20, 2012 at 05:19 P.M.If you have questions regarding your online application please contact Online Services at 1-877-423-4746.Your application tracking number is 5035962555.Be sure to write this number down or print this page for your records.In your application, you have asked for these benefits: • Food StampsAs a next step, your worker may ask for proof of some of the things you told us in your application. This checklist will helpyou gather these items. If you cant find something, your worker may be able to help you get the proof you need.Keep in mind that this list is based only on what you told us today. There may be other items that your worker will ask youto provide.Proof of IdentityProof of who you are, like a drivers license, ID card.Social Security NumberSocial Security numbers for everyone you want to receive benefits. Immigrants may potentially be eligible for benefitswithout a social security number.Proof of Citizenship or Immigration Status (Only for those seeking benefits)Proof of citizenship such as a birth certificate, U.S. passport, hospital record. Proof of immigration status such as residentimmigration card, passport, visa, I-94, I-181, or other Department of Homeland Security (DHS) documentation.Additional examples of Proof of Citizenship for Medicaid applicants can be found in Form 218.Proof of Job IncomeFor everyone who has a job or has had a job in the last three months, you will need to prove how much money they earnat each job they have. You can give your case worker pay stubs from employer(s) by providing at least one month or 4weeks of pay for each week paid in the month.COMPASS Apply For Benefits Page 1 www.compass.ga.gov
  2. 2. Application SummaryHere is a summary of what you told us, as well as important information about your rights and responsibilities.Help from OthersApplying on Your BehalfA friend or family memberBasic InformationYour Name Date of Birth Gender CountyMark A Ostrander 10/14/1963 Male GwinnettReceived Food Stamps this month in GA or another Nostate?Visually Impaired? NoHearing Impaired? NoInterpreter needed for interview? NoDo you and/or the applicant need assistance whencommunicating with us? If so, check all that apply?Primary Language EnglishIf you are not registered to vote where you live now, Nowould you like to apply to registerto vote here today?Is anyone in your home a If yes, did his or her job If yes, will he or she get more than $25 from a new jobmigrant or seasonal farm ended recently? or other source in the next 10 days?worker?NoWhere You Live Mailing Address1740 McDowell CT Lawrenceville, GA 30044Contact InformationPrimary Phone (770) 864-5525Alternative Phone (678) 787-1768Work PhoneEmail Address mostra1963@bellsouth.netBest way to get in touch with you Alternative PhonePhone Type (if Deaf or Hard of Hearing)Best time to get in touch with you Late AfternoonPeople In Your HomeCOMPASS Apply For Benefits Page 2 www.compass.ga.gov
  3. 3. Person Date of Birth Gender Marital StatusMark A Ostrander 10/14/1963 Male MarriedAge: 48 Previously Received Programs Requested Benefits? No Food Stamps Is this person known by Alternative Name any other name? No SSN SSN Application Date US Citizen? 419-04-8024 US Citizen When did this person When did this person get qualified, legal status in the come to the U.S. to live? U.S.? Does this person have a What country is this person from? sponsor? If this person has an Type of refugee If other, please specify immigrant registration number, what is it? Is this person a veteran or Military Service Number Veteran Status a spouse of a veteran? (not required for Food Stamp eligibility) Yes 419048024 Unknown Resident of GA? Where does he/she live? Yes In This Home Ethnicity and Race Is this person Hispanic? WhiteCOMPASS Apply For Benefits Page 3 www.compass.ga.gov
  4. 4. Person Date of Birth Gender Marital StatusLisa R Ostrander 03/24/1963 Female MarriedAge: 49 Previously Received Programs Requested Benefits? No Food Stamps Is this person known by Alternative Name any other name? No SSN SSN Application Date US Citizen? 424-96-4774 US Citizen When did this person When did this person get qualified, legal status in the come to the U.S. to live? U.S.? Does this person have a What country is this person from? sponsor? If this person has an Type of refugee If other, please specify immigrant registration number, what is it? Is this person a veteran or Military Service Number Veteran Status a spouse of a veteran? (not required for Food Stamp eligibility) No Resident of GA? Where does he/she live? Yes In This Home Ethnicity and Race Is this person Hispanic? No WhiteCOMPASS Apply For Benefits Page 4 www.compass.ga.gov
  5. 5. Person Date of Birth Gender Marital StatusRandall H Kirkley 08/27/1980 Male Never MarriedAge: 31 Previously Received Programs Requested Benefits? No Food Stamps Is this person known by Alternative Name any other name? No SSN SSN Application Date US Citizen? 419-15-1648 US Citizen When did this person When did this person get qualified, legal status in the come to the U.S. to live? U.S.? Does this person have a What country is this person from? sponsor? If this person has an Type of refugee If other, please specify immigrant registration number, what is it? Is this person a veteran or Military Service Number Veteran Status a spouse of a veteran? (not required for Food Stamp eligibility) No Resident of GA? Where does he/she live? Yes In This Home Ethnicity and Race Is this person Hispanic? No WhiteRelationship InformationPerson Relationships Do they buy food and eat meals together?Mark is the husband of Lisa YesAge: 48 is the stepfather of Randall YesPerson Relationships Do they buy food and eat meals together?Lisa is the mother of Randall YesAge: 49Questions About the People In Your HomeCOMPASS Apply For Benefits Page 5 www.compass.ga.gov
  6. 6. Person Blind or Drug Sanctioned Food Avoiding Violating Out of Disabled Felonies by FSET Stamp Prosecutio Parole State Disqualific n Benefits ationMark No No No No No No NoAge: 48Lisa No No No No No No NoAge: 49Randall No No No No No No NoAge: 31Liquid Asset InformationPerson Type Value Account Number Bank Name Other OwnersMark Checking Account $66.41 8810842966 Sun TrustAge: 48Job Income InformationPerson Name of Employer Address of EmployerMark Wallace ElectricAge: 48 Job Start Date Job End Date Date of First Paycheck Is currently on Last paycheck date Final Paycheck Amount strike Pay Period Amount Average Hours Hourly rate of pay Weekly $641 32 21 Additional Comments About Your Job Is this job part of a federal or state funded work-study program? NoSelf Employment InformationYou told us that no one in your home has this kind of income, benefit, or bill.Other Income QuestionsPerson Getting income from providing room and/or board?Mark NoAge: 48Lisa NoAge: 49Randall NoAge: 31COMPASS Apply For Benefits Page 6 www.compass.ga.gov
  7. 7. Other Income InformationYou told us that no one in your home has this kind of income, benefit, or bill.Housing Bills QuestionsDoes your household get housing or rent assistance? NoIf your household gets Public Housing Assistance, are you charged with a utilityexpense?Room and MealsPerson Paying for room and meals?Mark NoAge: 48Lisa NoAge: 49Randall NoAge: 31Housing Bills InformationRent or Lot Rent $900.00Landlords InformationName AddressChris Compton , GA Phone Number:(770) 682-7735Utility Bills QuestionsWhat is your households primary heating or cooling source? Gas And ElectricHas your household received help from Low Income Energy Assistance Program No(LIHEAP) at your current address, during the past 12 months?Utility Bills InformationCOMPASS Apply For Benefits Page 7 www.compass.ga.gov
  8. 8. Electricity $125.00Natural Gas $70.00Phone or Cell Phone Service $190.00Sewer $35.00Trash Removal $18.00Water $30.00Other Bills QuestionsPerson Medical Bills?Mark DentalAge: 48Lisa DentalAge: 49 Hospital Bills Prescription CostsRandall Hospital BillsAge: 31Dependent Care BillsYou told us that no one in your home has this kind of income, benefit, or bill.Child Support DetailsYou told us that no one in your home has this kind of income, benefit, or bill.School Enrollment InformationPerson Graduation Status Enrollment Status Earned high school equivalency or Not in schoolMark general equivalency diploma (GED)Age: 48 Type Of School School Name Date of Graduation Caring for a Caring for a Caring for a None of the In a federal or child under 6 child 6 to 12 child 6 to 12 above state funded years old? years old and years old and work-study daycare not enrolled in program? available? daycare? No No No No NoCOMPASS Apply For Benefits Page 8 www.compass.ga.gov
  9. 9. Person Graduation Status Enrollment Status Tenth Grade Not in schoolLisa Type Of School School Name Date of GraduationAge: 49 Caring for a Caring for a Caring for a None of the In a federal or child under 6 child 6 to 12 child 6 to 12 above state funded years old? years old and years old and work-study daycare not enrolled in program? available? daycare? No No No No NoPerson Graduation Status Enrollment Status Earned high school equivalency or Not in schoolRandall general equivalency diploma (GED)Age: 31 Type Of School School Name Date of Graduation Caring for a Caring for a Caring for a None of the In a federal or child under 6 child 6 to 12 child 6 to 12 above state funded years old? years old and years old and work-study daycare not enrolled in program? available? daycare? No No No No NoCOMPASS Apply For Benefits Page 9 www.compass.ga.gov
  10. 10. Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THEDEPARTMENT AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.This notice is effective April 14, 2003. It is provided to you pursuant to provisions of the Health InsurancePortability and Accountability Act of 1996 and related federal regulations. If you have questions about thisNotice, please contact the Legal Services Office at the address below.The Department of Human Services is an agency of the State of Georgia responsible for numerous programs, which dealwith medical and other confidential information. Both federal and state laws establish strict requirements for mostprograms regarding the disclosure of confidential information, and the Department must comply with those laws. Forsituations where more stringent disclosure requirements do not apply, this Notice of Privacy Practices describes how theDepartment may use and disclose your protected health information for treatment, payment, health care operations andfor certain other purposes. This notice relates only to health information. It describes your rights to access and controlyour protected health information, and provides information about your right to make a complaint if you believe theDepartment has improperly used or disclosed your "protected health information". Protected health information isinformation that may personally identify you and relates to your past, present or future physical or mental health orcondition and related health care services. The Department is required to abide by the terms of this Notice of PrivacyPractices, and may change the terms of this notice, at any time. A new notice will be effective for all protected healthinformation that the Department maintains at the time of issuance. Upon request, the Department will provide you with arevised Notice of Privacy Practices by posting copies at its facilities, publication on the Departments website, in responseto a telephone or facsimile request to the Privacy Coordinator, or in person at any facility where you receive services fromthe Department.1. Uses and Disclosures of Protected Health InformationYour protected health information may be used and disclosed by the Department, its administrative and clinical staff andothers involved in your care and treatment for the purpose of providing health care services to you, and to assist inobtaining payment of your health care bills.Treatment: Your protected health information may be used to provide, coordinate, or manage your health care and anyrelated services, including coordination of your health care with a third party that has your permission to have access toyour protected health information, such as, for example, a health care professional who may be treating you, or to anotherhealth care provider such as a specialist or laboratory.Payment: Your protected health information may be used to obtain payment for your health care services. For example,this may include activities that a health insurance plan requires before it approves or pays for health care services suchas; making a determination of eligibility or coverage, reviewing services provided to you for medical necessity, andundertaking utilization review activities.Health Care Operations: The Department may use or disclose your protected health information to support the businessactivities of the Department, including, for example, but not limited to, quality assessment activities, employee reviewCOMPASS Apply For Benefits Page 10 www.compass.ga.gov
  11. 11. activities, training, licensing, and other business activities. The Department may use a sign-in sheet at the registrationdesk at any facility where services are provided. You may be asked to provide your name and other necessaryinformation, and you may be called by name in the waiting room when a staff member is ready to see you, and yourprotected health information may be used to contact you about appointments or for other operational reasons. Yourprotected health information may be shared with third party "business associates" who perform various activities thatassist us in the provision of your services.Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to ObjectOther uses and disclosures of your protected health information will be made only with your written authorization, whichyou may revoke in writing at any time, except as permitted or required by law as described below.Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to ObjectThe Department may use and disclose your protected health information in the following instances. You have theopportunity to agree or object to the use or disclosure of all or part of your protected health information.Unless you object, the Department may disclose protected health information for a facility directory or to a family member,relative, or any other person you identify, information related to that persons involvement in your health care and may useor disclose protected health information to notify or assist in notifying a family member, personal representative or otherperson responsible for your care of your location, general condition or death. The Department may use or disclose yourprotected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinateuses and disclosures to family or other individuals involved in your health care. Objections may be made orally or inwriting.Permitted or Required Uses and Disclosures without Your Authorization or Opportunity to ObjectThe Department may use or disclose your protected health information without your authorization when required to do soby law; for public health purposes; to a person who may be at risk of contracting a communicable disease; to a healthoversight agency; to an authority authorized to receive reports of abuse or neglect; in certain legal proceedings; and forcertain law enforcement purposes. Protected health information may also be disclosed without your authorization to acoroner, medical examiner or funeral director; for certain approved research purposes; to prevent or lessen a threat tohealth or safety; and to law enforcement authorities for identification or apprehension of an individual.Required Uses and Disclosures: Under the law, the Department must make disclosures to you and when required by theSecretary of the Department of Health and Human Services to investigate or determine the Departments compliance withthe requirements of the Privacy Rule at 45 CFR Sections 164.500 et. seq.2. Your Rights under the federal Privacy RuleIf you would like to create an account so you can come back to your application later, click the Create Account button.COMPASS Apply For Benefits Page 11 www.compass.ga.gov
  12. 12. You have the right to inspect and copy your protected health information. Upon written request, you may inspect andobtain a copy of protected health information about you for as long as the Department maintains the protected healthinformation. This information includes medical and billing records and other records the Department uses for makingmedical and other decisions about you. A reasonable, cost-based fee for copying, postage and labor expense may apply.Under federal law you may not inspect or copy information compiled in anticipation of, or for use in, a civil, criminal, oradministrative proceeding, or protected health information that is subject to a federal or state law prohibiting access tosuch information.You have the right to request restriction of your protected health information. You may ask in writing that the Departmentnot use or disclose any part of your protected health information for the purposes of treatment, payment or healthcareoperations, and not to disclose protected health information to family members or friends who may be involved in yourcare. Such a request must state the specific restriction requested and to whom you want the restriction to apply. TheDepartment is not required to agree to a restriction you request, and if the Department believes it is in your best interest topermit use and disclosure of your protected health information, your protected health information will not be restricted,except as required by law. If the Department does agree to the requested restriction, the Department may not use ordisclose your protected health information in violation of that restriction unless it is needed to provide emergencytreatment.You have the right to request to receive confidential communications from us by alternative means or at an alternativelocation. Upon written request, the Department will accommodate reasonable requests for alternative means for thecommunication of confidential information, but may condition this accommodation upon your provision of an alternativeaddress or other method of contact. The Department will not request an explanation from you as to the basis for therequest.You may have the right to request amendment of your protected health information. If the Department created yourprotected health information, you may request in writing an amendment of that information for as long as it is maintainedby the Department. The Department may deny your request for an amendment, and if it does so will provide informationas to any further rights you may have with respect to such denial.You have the right to receive an accounting of certain disclosures the Department has made of your protected healthinformation. This right applies only to disclosures for purposes other than treatment, payment or healthcare operations,excluding any disclosures the Department made to you, to family members or friends involved in your care, or for nationalsecurity, intelligence or notification purposes. Upon written request, you have the right to receive legally specifiedinformation regarding disclosures occurring after April 14, 2003, subject to certain exceptions, restrictions and limitations.You have the right to obtain a paper copy of this notice from the Department, upon request. All written requests regardingyour rights as set forth above should be sent to the Privacy Coordinator for the DHS Division, Office or facility whichmaintains your PHI.3. Complaints related to use or disclosure of your protected health informationCOMPASS Apply For Benefits Page 12 www.compass.ga.gov
  13. 13. You may file a complaint if you believe your health information and privacy rights have been violated. You may file acomplaint with the DHS, Division of Family and Children Services by calling 404-463-7291 or by mailing your complaint to:DFCS HIPAA Privacy Coordinator, 2 Peachtree Street, N.W. Suite 19-244, Atlanta, Georgia 30303-3142.*Please DO NOT send your application for services to this address*I understand that an electronic signature has the same legal effect and can be enforced in the same way as a writtensignature. I have read and understand this Notice of Privacy Practices.Mark A OstranderJune 20, 2012 at 05:19 P.M.COMPASS Apply For Benefits Page 13 www.compass.ga.gov
  14. 14. Electronic SignatureI have agreed to submit this application for myself and/or my family. By signing this application electronically, I certifyunder penalty of perjury and false swearing that my answers are true and accurate to the best of my knowledge, includinginformation provided about the citizenship or immigration status for each household member applying for benefits. I alsocertify that:• I understand the questions and statements on this application.• I have read and understand my Rights & Responsibilities.• I understand the penalties for giving false information or breaking the rules.• I understand that the agency may contact other persons or organizations to obtain needed proof of my eligibility and level of benefits.• I understand that I am not required to report reduction or loss of income, that that I may be able to get a higher Food Stamps benefit if I do. I understand that as long as I do not report this reduction or loss in income, my Food Stamps benefit will not increase.• I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want to receive a deduction for the unreported or unverified expenses.• I understand I can be punished by law if I do not tell the complete truth.• I certify that all of the information provided on this application is true and correct to the best of my knowledge.I understand that an electronic signature has the same legal effect and can be enforced in the same way as a writtensignature. By checking this box and typing my name below, I am electronically signing my application.Mark A OstranderJune 20, 2012 at 05:19 P.M.COMPASS Apply For Benefits Page 14 www.compass.ga.gov
  15. 15. Food Stamp Rights and ResponsibilitiesPlease read the following information carefully.YOU HAVE THE RIGHT TO• receive an application on the day you ask for it.• have your application accepted when you file it.• have an adult apply for your household if you are unable to.• a telephone interview.• have your EBT card and PIN within 30 days of the date you file your application, if eligible, or• have your EBT card and PIN within 7 days of the date you file your application, if eligible for expedited services.• receive fair treatment without regard to age, sex, race, color, handicap, religious creed, national origin, or political beliefs.• have a fair hearing if you disagree with any action on your case.• examine your case file and the rules of the program.• be notified in advance if your benefits are reduced or stopped due to a change that is not reported in writing.YOUR RESPONSIBILITIES:• you must answer all questions completely.• you must sign your name to certify, under penalty of perjury, that all answers are true.• you must provide proof that you are eligible.• Reporting when your households total gross monthly income is more than 130% of the Federal Poverty Level for the households size within 10 days of the end of the month that the change occurred.• do not sell, trade, or give away your food stamp benefits.• use food stamp benefits to buy only eligible items.• For more information about Community Outreach Services, please visit our website at:http://www.dfcs.dhr.georgia.gov or call 1-877-423-4746 or 404-657-3426.In all programs, you have the right to:• request a fair hearing in writing or in person. You have the right to be represented by a household member, legal counsel, a relative, a friend or other spokesperson. If you are not satisfied with the action we have taken on your case, you can request a hearing by contacting the county office where you applied for benefits or by calling 1-877- 423-4746.• review some of the material and information in your case file. However, you may not be able to see all of the information in the case file, such as names of people who have given us information about you or your household members or information about any criminal prosecutions involving you or any of your household members.• decide if you want to provide a Social Security Number (SSN), citizenship, or immigration status. Only the people who give information to us about their SSN, citizenship, or immigration status will be eligible to receive benefits. This information will be used to check the "Income and Eligibility Verification System" (IEVS) and other computer matches with other agencies to verify your income and other points of eligibility. We may also give this information to other Federal and State agencies to review and to law enforcement officials for them to use in catching people who are running from the law. If your household has a Food Stamp or SNAP claim, the information on this application, including the SSN, may be given to Federal and State agencies and private claims collection agencies for them toCOMPASS Apply For Benefits Page 15 www.compass.ga.gov
  16. 16. use in collecting the claim. We will not share your information with the United States Citizenship and Immigration Services (USCIS); however, if alien status information has been submitted on your application, this information may be subject to verification through USCIS and may affect your households eligibility and benefit level. We will not deny help to people asking for help because other household members do not provide their SSN, citizenship, or immigration status. The following federal laws and regulations: 7 U.S.C. § 2011-2036, 45 C.F.R. § 205.52, 42 C.F.R. § 435.910, 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security number(s).• decide if you want to provide information about your race and ethnicity. We collect data on race, color, and national origin to ensure we are in compliance with Federal civil rights laws. By providing this information, you will assist us in administering our programs in a non-discriminatory manner. Your household is not required to give us this information and it will not affect your eligibility or benefit level.In all programs, you are responsible for:• giving your worker correct information and providing proof of statements needed to receive benefits. When you sign this form, you are giving your worker permission to get information from your employer, bank, neighbor or others so we can make sure you are receiving the correct amount of benefits.• telling the truth at all times. If you or someone who is applying for you provides incorrect information, you may be committing a crime, and you may go to jail.• providing proof that you or anyone in your household applying for benefits is a U.S. citizen or eligible immigrant. Note: Your worker will give you a list of the ways you can prove your citizenship or immigration status.• reporting certain changes in your household situation. Each program has different reporting requirements. See the responsibilities section for each program for things you need to report.What Other Responsibilities Do I Have in the Food Stamp Program?In the Food Stamp Program, you are also responsible for:• cooperating with state and federal personnel who work for Fraud Prevention or the Office of Investigative Services and who are doing special case reviews. If you do not cooperate and we cannot determine that you are still eligible for Food Stamps, your case may be denied or closed.• cooperating with Quality Control reviewers when they call or come to your home to interview you about the information you have given your case manager. If you do not cooperate with them, your case may be denied or closed.• repaying benefits you should not have received.• reporting when your households total gross monthly income is more than 130% of the Federal Poverty Level for your households size. You will be given a form 339, Simplified Reporting Requirement Notice, which explains more about this.If you are an able-bodied adult without dependents (ABAWD), you must report when your work hours fall below 20 hoursper week or 80 hours per month.COMPASS Apply For Benefits Page 16 www.compass.ga.gov
  17. 17. What Are My Rights and Responsibilities for Reporting Household Expenses in the Food StampProgram?In the Food Stamp Program, certain household expenses such as shelter costs, medical bills, dependant care costs, andchild support paid outside the home may affect the amount of benefits you receive. If you have heating or coolingexpenses, you may be eligible to receive the standard utility allowance. If you have only one utility expense and it is NOTa heating or cooling expense, you may be eligible to receive a deduction for the actual expense incurred. If you want us toconsider these expenses, you are responsible for reporting and verifying them. If you fail to report or verify theseexpenses, we will not use them to determine your benefit amount.What Are the Penalties in the Food Stamp Program?In the Food Stamp Program, there are penalties:If you ... You will lose food benefits ...• hide information or dont tell the truth. • for 12 months for the first offense,• use EBT cards that belong to someone else. 24 months for the second offense,• use food benefits to buy alcohol or tobacco. and permanently for the third• trade or sell benefits or EBT cards. offense.• trade or sell food benefits for drugs and were convicted prior to 8/22/96. • for 12 months for the first offense and permanently for the second offense.• trade or sell food benefits for drugs and were • for 24 months for the first offense convicted of less than $500 on or after 8/22/96. and permanently for the second offense.• trade or sell food benefits for drugs and were • permanently. convicted of $500 or more on or after 8/22/96.• trade food benefits for firearms, • permanently. ammunition or explosives.• give false information about where you • for 10 years. live so you can get food stamp benefits in more than one state.• commit and are convicted of a felony related to • permanently. possession, use or distribution of drugs, on or after 8/22/96.• flee to avoid prosecution, custody or confinement for a felony. • until you are no longer fleeing.• violate a condition of your probation or parole. • until you are no longer a probation or parole violator.Non-Discrimination StatementCOMPASS Apply For Benefits Page 17 www.compass.ga.gov
  18. 18. In accordance with Federal law and U. S. Department of Agriculture (USDA) and U.S. Department of Health and HumanServices (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age,or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion orpolitical beliefs.To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400Independence Avenue, S.W., Washington D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). WriteHHS, Director, Office for Civil Rights, Room 509-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call(202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin,or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call theGeorgia Department of Community Healths Office of Constituent Services at (404)656-4496.You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street,N.W., Suite 19-248, Atlanta, GA 30303, or call (404) 657-3735 or fax (404) 463-3978.COMPASS Apply For Benefits Page 18 www.compass.ga.gov

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