Connecticut General Statutes Title 4. Management of State Agencies § 4-66d. Standardized form for notification of possible reimbursement liability

(a) The Secretary of the Office of Policy and Management shall develop a standardized form of notice for the Departments of Social Services, Children and Families, Developmental Services and Mental Health and Addiction Services for the purpose of disclosing to an applicant or recipient of care or support, or the legally liable relative, as defined in subsection (c) of section 4a-12, of a person receiving care or support, the possibility of liability for reimbursement of any amount paid by the state on behalf of the care or support of an applicant, recipient or child. Said form shall include the following: (1) Whether payments required are full or partial payment of moneys owed to the department; (2) that the applicant or recipient of care or support, or the legally liable relative may be liable for the entire cost of care or support; and (3) that upon request, at the end of care or support, itemization of costs and list of services provided. Said form may be included in an application for care or support.

(b) The Departments of Social Services, Children and Families, Developmental Services and Mental Health and Addiction Services shall provide the form of notice established pursuant to subsection (a) of this section to all applicants or recipients of care or support or the legally liable relatives, as defined in subsection (c) of section 4a-12, of a child receiving care or support, if the whereabouts of such relatives are known.