OPWDD Family Reimbursement Application

Applicant Information

Name Of Individual Receiving Services

TABS #

Address

City

State

ZIP

County

Date Of Birth

Number Of People In Home

Family Information

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Care Manager Contact

Care Manager Name

Care Manager Phone

Care Manager Email

Address

City

State

ZIP

Fiscal Intermediary (If Applicable)

Name

Agency

Phone

Additional Information

Reimbursements Applied For

List all reimbursement applied for and/or received this contract year. This information MUST be reported. Please be advised that $3,000 is the maximum total amount that may be reimbursed. If you have a large reimbursement request that exceeds an agency internal cap and you are submitting to multiple agencies for partial reimbursement, you must indicate this in the spaces below.

Agency

Date

Amount

Status

Please Attach Documents

Notice of Decision or other OPWDD Eligibility Document approved by DDRO

(If current documentation is not on file with provider agency)

Signed application, receipts/invoice copy, respite verification forms

(If receipt has been submitted to another agency for partial reimbursement, list what agency has the receipt)

Clinical justification/letter from physician or clinician

(If the request is for a clinical item/service)

Recent self-direction expense report/budget copy

Provide a copy if enrolled in Self-Direction which verifies that Family Reimbursement is accounted for.

Recent life plan with FSS family reimbursement

Provide a copy if enrolled with a CCO properly documented.

In the event that a claim for goods or services is discovered to be fraudulent, the agency to which that reimbursement application was submitted is to be notified (if not the discovering entity) and will investigate the request in question and all documentation provided with the reimbursement request. In the event that the fraudulent claim is confirmed, the individual/family will be required to pay the amount reimbursed back to the agency (if the service/good was already reimbursed) and will be suspended from any future reimbursement for goods and services for a period of time determined by the agency and OPWDD. The recipient of the reimbursement may also be subject to legal actions as determined by the agency and OPWDD.

Families may submit requests for Reimbursement to the RO or a FSS Reimbursement provider agency at any time, depending upon which entity administers the reimbursement program in that region, using the form provided by the Family Reimbursement provider agency or obtained from the individual’s Care Manager or Care Coordinator. Funds are available only on a contract year basis. Any authorized, but unused, reimbursements may not be carried over by a receiving family from one year to the next. For self-directing individuals, verification is made to ensure that the FSS program is included in the current budget. Inclusion of funding in the budget does not guarantee that the request will be approved. Reimbursement requests must be consistent with FSS guidelines. Applications may be submitted to any of the Family Reimbursement Program providers by individuals, families, case managers or advocates. Anything submitted more than 90 days after purchase/occurrence will be awarded per the discretion of the Reimbursement Program provider. Applications that are not filled out in full will be returned, and payment will be delayed.

I HAVE READ THE STATEMENT ABOVE AND UNDERSTAND THAT INFORMATION RELATED TO MY REQUEST FOR REIMBURSEMENT MAY BE MUTUALLY SHARED WITH AND/OR RECEIVED FROM OTHER AGENCIES WITHIN THE OPWDD REGION/DISTRICT

Agrees to Application Statement

Yes

Parent/Guardian Signature

Date Completed

Name If Submitted By Care Coordinator

Name of Care Coordination Organization (CCO)