Family Support Services Application

Applicant Information

Name Of Individual Receiving Services

Parent/Guardian Name

Parent/Guardian Email

Individual connected with a Care Manager?

No Yes

If yes, Care Manager Name

If yes, Care Manager Email

Individual enrolled in waiver?

No Yes

Individual enrolled in self-direction?

No Yes

Individual enrolled in Medicaid?

No Yes

Please Attach Documents

Signed Completed Application
*Required

Letter of Eligibility
*Required

Life Plan or Plan of Care

If enrolled with a CCO, attach the most recent copy with FSS family reimbursement properly documented

Respite Verification Forms

If applying for reimbursed respite

Receipts/Invoices

If applying for goods/services already purchased

Clinical Justification/Letter From Physician or Clinician

If the request is for a clinical item/service

Self-Direction Budget/Report and/or Denial Letter

If enrolled in Self-Direction

Any additional supporting documentation to review