DCH-0495.pdf

This document is a Patient Fund Release Authorization form (DCH-0495, Rev. 4-19) issued by the Michigan Department of Health and Human Services for managing patient or resident personal funds. The form is designed to document and authorize the disbursement of patient funds for various purposes including phone cards, debit cards, cash for outings, shopper expenses, discharge funds, check requests, and other transactions. The form requires completion by unit staff and includes fields for itemized descriptions, actual costs, estimated total costs, and approval signatures from a Patient Affairs Officer and Clinician/Program Director before any funds are released.

The form establishes a multi-step accountability process with specific approval requirements and funding classifications. Funds are categorized as indigent, restricted, or unrestricted, and all disbursements must be recorded with corresponding accounting codes and withdrawal codes. The document includes a distribution protocol with copies designated for accounting, patient affairs, shoppers (optional), and staff or recipients. All accounting personnel must certify the accountability of funds upon transaction completion, and the form requires signatures from the patient, witnesses, and funds recipients to ensure proper documentation and audit trail compliance.