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Application

Please complete the application below to get started

This application must be completed in full in a single sitting . Once you have completed everything and submitted the application, I will reach back out to you to talk about next steps. If you have any questions, please send me a message. I’m here to help!

Step 1 of 5

Client Information

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Client Date of Admission

Client Name(Required)

First Last

Client Email Address(Required)

Enter Email Confirm Email

Client Phone(Required)

Client Social Security Number(Required)

Date of Birth(Required)

Client Current Address(Required)

Street Address Address Line 2 City State ZIP Code

How long has client lived at this address?(Required)

Client Former Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Race(Required)

Client Marital Status(Required)

# of people in the home(Required)

City and State of Client's Birth(Required)

City State

Maiden Name of Client's Mother(Required)

Name and relationship of all persons living with client(Required)

Referring Agency Name

Referring Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Case Manager's Name

Case Manager's Email

Case Manager's Phone

Next of Kin / Emergency Contact Name

Next of Kin / Emergency Contact Phone

Next of Kin / Emergency Contact's Relationship to Applicant

Next of Kin / Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does the client receive food stamps?(Required)

Amount

Medicaid / Medicare Number

Life Insurance Information

Do the client have any assets?(Required)

(e.g. bank accounts, cars, real estate)

List assets

Has the client ever been convicted of a felony?(Required)

Best Time To Call You

When is the best time for us to reach you via telephone?

Reason For Service

Referral Source(Required)

What is your disability?

Are there family members of friends available to provide this type of service?(Required)

Do you have a court-appointed legal guardian?(Required)

Guardian Name(Required)

Guardian Phone(Required)

Guardian Address(Required)

Street Address Address Line 2 City State ZIP Code

Have you previously had a Representative Payee?(Required)

** If NO, please print the physician form and have it completed. You are responsible for faxing or emailing the completed form back to 2nd Chance Management, Inc.

Agency Responsibility

MY NEED FOR A PAYEE AND MY SELECTION FOR MY PAYEE

The Social Security Administration has determined that I need assistance in managing my benefits. This means that my benefits will be sent to a representative payee who is responsible for managing my benefits in my best interest. I choose to have 2nd Chance Management, Inc. (2nd Chance) serve as my representative payee.

MY RIGHTS

I understand that I have the right to appeal social security’s decision as to who will be my representative payee. I will contact a social security office if I want to appeal.
I understand that I have the right to appeal the determination of social security that I need a payee. If I choose to appeal, I understand that I have the right to review the information in my file and that I can submit new evidence for consideration and that I must file my appeal within 60 days.
I understand that if I do not file my appeal within 60 days that I must have a good reason for being late. I understand that I must ask for the appeal in writing and I will contact a social security office if I want to appeal.

GRIEVANCE POLICY

Stage 1: Within 30 days of the incident of complaint, there should be an informal discussion with the service staff directly involved.

Stage 2: Within 14 days of stage 1 A written complaint should be submitted to 2nd Chance, Attention: Executive Director Payee Services Program. A response from the Program Director will be given within 14 working days of the complaint.

Stage 3: A formal appeal to 2nd Chance addressed to the Executive Director must be filed within 14 days of completing stage 2. The Executive Director will give a response within 14 days.

FRAUD POLICY

2nd Chance (the Company) is committed to preventing, identifying, and reporting any fraudulent activity related to the Company’s services, activities and administration of grants. Fraud may include but is not limited to false statements provided by or to staff, contractors, clients, beneficiaries and stakeholders. Fraudulent activities may include but are not limited to knowingly misrepresenting income or expenses, assisting or counseling anyone to misrepresent facts or circumstances related to eligibility for programs or benefits, bribery, kickbacks, theft or embezzlement, forgery or alteration of documents, destruction or concealment of records, profiting from insider knowledge, or a conflict of interest.

The Company will investigate any reports of fraud. The Company reserves the right to involve law enforcement authorities in its investigation. Any documented fraudulent activity may result in administrative or criminal action being taken against those involved including termination from any program sponsored by the Company or termination from employment by the Company. The Company will not retaliate against any party who reports fraud, criminal activities or other program irregularities. Any suspected fraudulent activity should be reported to the Company’s currently appointed Risk Manager with sufficient specificity to facilitate an investigation.

ACKNOWLEDGMENT

My signature indicates the following items have been discussed with me to my satisfaction and any questions have been answered.

2nd Chance requirements have been explained:
Services are made available to clients without regard to race, religion, creed, or origin.

The Agency’s expectations of me have been explained:
A client is expected to provide truthful, accurate information to the best of his/her knowledge. The client needs to notify the Agency when changes occur in health, living conditions, or employment and income.

My rights and responsibilities as a client have been explained:
A client has the right to confidential treatment of information provided to any Agency staff member. The client’s responsibility is to provide adequate, accurate information so that the agency will provide efficient service to meet client needs.

Hours of service availability have been explained to me:
Agency hours are Monday – Thursday, 9:30am-3:30pm and CLOSED: Saturday and Sunday. Generally, services are not available after 4:00pm, on weekends, or on scheduled holidays. Please call to schedule appointment.

Date(Required)

Client Signature – Please sign in the box below

By signing below, I confirm that I have read and understand the information provided in this document.

Client Full Name(Required)

Release of Information

Client Name(Required)

First Last

Client Social Security Number(Required)

Client Date of Birth(Required)

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

I hereby authorize: 2nd Chance Management, Inc. | Richmond, VA 23225 | 804-745-1375 permission to use/disclose/exchange/release information regarding my case for the purpose of my financial management.

To/With:

**Please leave the following section blank if you are not sure at this time.

Name of Person or Organization

Phone

Fax

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Purpose of use/disclosure/exchange of information is: (Check all that apply)

Legal

Benefits/Service Eligibility

Discharge Planning

As the person signing this authorization, I understand that I am giving my permission to the above named entity for disclosure of confidential financial records. I understand that:

2nd Chance Management, Inc. cannot condition payment on my willingness to sign this authorization. I may refuse to sign this authorization.
This authorization will become effective upon the date signed below unless noted otherwise.
Only the information needed to satisfy the stated purpose of this disclosure will be shared. I understand this will include information added after the authorization origination date and up until the authorization expiration date.
That I have the right to revoke my consent, but that my revocation is not effective until the delivery in writing to the person who is in possession of my records or receiving the information.
That my consent may be revoked by the provider to the extent that the provider, person or program authorized to make the disclosure has already taken action in reliance on my consent.
I understand that my consent is voluntary.
A copy of this authorization and a notation concerning the persons or agencies to whom disclosure was made shall be included with my original financial records.

Unless revoked this authorization will expire on the following date:(Required)

Date(Required)

Client Signature – Please sign below

Client Full Name(Required)

Phone

This field is for validation purposes and should be left unchanged.

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Application

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Client Information

Reason For Service

MONTHLY INCOME / EXPENSES

Monthly Income

Housing Expenses

Utilities (monthly average)

Medical Expenses

Basic Needs

Transportation

Insurance

Other Expenses

Agency Responsibility

MY NEED FOR A PAYEE AND MY SELECTION FOR MY PAYEE

MY RIGHTS

GRIEVANCE POLICY

FRAUD POLICY

ACKNOWLEDGMENT

Release of Information

To/With:

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Phone: 804-745-1375 | Fax: 804-291-3313 | Address: 1906 Cedarhurst Drive, Richmond, VA 23225

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