Gateway DSA - Eligibility Verification Form

Gateway Down Syndrome Association Eligibility Verification Form

This secure form is used to request information from our members. This information is provided to our to our local state funding agencies in various counties to confirm identity and eligibility of services. These agencies provide important funding for our programs and services. Thank you for providing this information so that we can keep our programs and services free or low cost to our families.
Parent/Caregiver Name

First NameLast Name
Parent/Caregiver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver County
Parent/Caregiver E-mail
example@example.com
Parent/Caregiver Phone Number (do not include "1" - area code and phone number only)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Caregiver Relationship to Individual with Down syndrome

Other
Name of Individual with Down syndrome

First NameLast Name
Birthdate of Individual with Down syndrome

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender of Individual with Down syndrome
Race of Individual with Down syndrome

Other
Ethnicity of Individual with Down syndrome
Does your household receive public assistance (Medicaid, SSI, SNAP, WIC, etc)? Sometimes we receive grant money to help families in need.
Eligibility Verification can be provided

in TWO possible ways

1)   Provide your child’s DMH or IDHS number. This number is assigned when you connect with the Division of Developmental Disabilities in your state. You can apply for this at any time in your child’s life, but we recommend doing this by the time your child turns 3.

OR

2)   Provide your child’s Social Security Number AND one of the following:
- Individualized Family Support Plan (0-2 years old)
- Confirmation of Developmental Disability Form (any age)
For Missouri:

To learn more about the Department of Mental Health-Division of Developmental Disabilities: https://dmh.mo.gov/dev-disabilities/individual-family-guardian-info

Click the link to enter your county and then locate the phone number to get started: https://dmh.mo.gov/dev-disabilities/regional-offices

For Illinois:

To learn more about the Department of Human Services-Division of Developmental Disabilities: https://www.dhs.state.il.us/page.aspx?item=29761

Click the link to get started: https://www.dhs.state.il.us/page.aspx?module=12
OPTION 1
DMH (Department of Mental Health) Number for Missouri
IDHS (Illinois Department of Human Services) Number for Illinois
OPTION 2
Proof of Identity

Provide the SSN of the individual with Down syndrome

AND

  Proof of Eligibility

0-2 Years Old

Copy of (IFSP) Individualized Family Service Plan (from First Steps in MO or Child and Family Connections in IL). This document provides eligibility for one to 3 years.

OR

All Ages

Confirmation of Developmental Disability Form.  This document provides eligibility for life.
Proof of Identity: Enter the Social Security Number of the Individual with Down syndrome (no dashes)
Social Security Number (no dashes) OR DMH/IDHS number of Individual with Down syndrome
The number provided above is the:
Proof of Eligibility/Diagnosis: If you are providing a copy of your child's Individualized Family Service Plan, upload it here. Otherwise, provide your child's doctor with a copy of the Confirmation of Developmental Disability form.

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Gateway Down Syndrome Association Eligibility Verification Form

Eligibility Verification can be provided

in TWO possible ways

OPTION 1

OPTION 2

Proof of Identity

AND

Proof of Eligibility