DCH-0495.pdf
PDF 100 KB Posted
- Attached to
- DCH-0495 PATIENT FUND RELEASE AUTHORIZATION
- Solicitation number
- RFQ-171-250000000249-1
- Issued by
- Michigan
About this file
This is a Patient Fund Release Authorization form from the Michigan Department of Health and Human Services (Form DCH-0495, Rev. 4-19). The form facilitates the release and tracking of patient funds for various purposes including phone cards, Debitek cards, cash for outings, shopper cash, discharge funds, check requests, LOA (Leave of Absence) funds, and other transactions. The form requires multiple levels of authorization including signatures from the patient/resident, Patient Affairs Officer, and Clinician/Program Director, with options for disbursement via cash, check, or Debitek card.
The form includes detailed accounting controls with fields for tracking indigent, restricted, and unrestricted funds, along with specific D/W (Debit/Withdrawal) codes and account numbers for up to three different accounts. The document uses a four-part color-coded distribution system (White-Accounting, Yellow-Patient Affairs, Pink-Shopper/Optional, Goldenrod-Staff/Recipient) to ensure proper routing and record-keeping. The form includes verification of sufficient funds, purchase approval/denial, charge limits, and requires certification of accountability for all transactions by accounting personnel.
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Other files
| File | Type | Posted |
|---|---|---|
| State of Michigan Print Mail Management Terms Conditions (1).docx | DOCX document | |
| standard-contract-terms-short-form (7) (7) (1).docx | DOCX document | |
| DCH-0495 (WR) Patient Fund Release Authorization 2-25 Bid Request.docx | DOCX document |
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Text version
DCH-0495 (Rev. 4-19) Previous edition obsolete.
PATIENT FUND RELEASE AUTHORIZATION
Michigan Department of Health and Human Services
Patient/Resident Name Batch Number Document Number
Patient Case Number Unit
Staff Completing Form Disbursement requested Cash Check Debitek Card Patient/Resident Signature
Item Description Notes Actual Cost
1 Phone Card 2 Debitek Card 3 Cash for Outing 4 Cash for Shopper 5 Discharge Funds 6 Check Request 7 LOA Funds 8 Other Transactions
Total Estimated Cost (Written Out) Total Purchases Charge Limit Patient Affairs Officer Signature Date
Approved Denied Sufficient Funds Initials Clinician/Program Director Signature Date
Yes No Check Payable To: (Last, First and Middle Name) Street Address
Check Mailed To: (Last, First and Middle Name) City, State, Zip Code
Funds Released to: (Signature) Shopper Patient Other Date
Patient Signature Date Witness Signature Date
Ac co un tin g U se O nl y
Amount of Funds Withdrawn Indigent Restricted Unrestricted
Check Number D/W Code
Acct.
D/W Code
Acct.
D/W Code
Acct.
Treasury Manual
I certify the accountability of all funds pertaining to this transaction.
Accounting Personnel Signature Date
Remarks
Distribution: White-Accounting; Yellow-Patient Affairs; Pink-Shopper/Optional; Goldenrod-Staff/Recipient
File details come from the government source that posted it. Updated .