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