Request for Financial Transaction Services Payment

Request for Financial Transaction Services Payment - Aging Waiver
Participant's First and Last Name: *

First Name Last Name
Care Plan Start Date *

Month Day Year
Start Date of Care Plan
Care Plan End Date *

Month Day Year
End Date of Care Plan
Participant's Address

Street Address

Street Address Line 2

City State

Zip Code
Participant's Medicaid ID: *
Participant's Date of Birth: *

Month Day Year
Date
Area Agency on Aging (AAA): *
Date of Request: *

Month Day Year
Date
Email *

Confirmation Email example@example.com
Has the AAA Approved the below service(s) or item(s) on the care plan? *

Yes No
Date of Care Plan Approval *

Month Day Year
Date
Does this Request Require Division of Aging & Adult Services (DAAS) approval?

Yes No
If yes, provide the approval date:

Month Day Year
Date
DAAS approval received from:
Request Type? *

Reimbursement (Receipts) Direct Payment (Invoice/W9) Online Order (must include direct links)
Make Check Payable To (Vendor): *
Enter website for online orders
Vendor FEIN or SSN:
File Upload - Vendor W9

Cancel of
Vendor Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Chore Services

HCPCS Code S5120
Do you have an entry for this section? (HCPCS Code S5120)

Yes
Service Code Start Date

Month Day Year
S5120 Start Date on Care Plan
Service Code End Date

Month Day Year
S5120 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS approval is required for services costing more than $1000.00
File Upload

Cancel of
Environmental Accessibility Adaptations

HCPCS Code S5165
Do you have an entry for this section? (HCPCS Code S5165)

Yes
Service Code Start Date

Month Day Year
S5165 Start Date on Care Plan
Service Code End Date

Month Day Year
S5165 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS approval is required for services costing more than $2000.00
File Upload

Cancel of
Supplemental Meals

HCPCS Code S5170
Do you have an entry for this section? (HCPCS Code S5170)

Yes
Service Code Start Date

Month Day Year
S5170 Start Date on Care Plan
Service Code End Date

Month Day Year
S5170 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
Specialized Medical Equipment/Supplies/Assistive Technology

HCPCS Code T2029
Do you have an entry for this section? (HCPCS Code T2029)

Yes
Service Code Start Date

Month Day Year
T2029 Start Date on Care Plan
Service Code End Date

Month Day Year
T2029 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS Approval for items over $1000.00
File Upload

Cancel of
Community Living Services

HCPCS Code T2038
Do you have an entry for this section? (HCPCS Code T2038)

Yes
Service Code Start Date

Month Day Year
T2038 Start Date on Care Plan
Service Code End Date

Month Day Year
T2038 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS Approval for items over $1000.00
File Upload

Cancel of
Total Check Amount
By signing this form, I attest that services have been delivered and received consistent with the participant’s approved care plan and that this payment request is in accordance with the AW Program regulations. I understand that payment of this claim will be from Federal and State funds, and that false claims, statements or documents or concealment of a material fact may be prosecuted under applicable Federal or State laws. Any misuse of funds may result in being fined or penalized, including but not limited to repayment of a claim.
AAA FTS Coordinator Name (Print) *

First Name Last Name
AAA FTS Coordinator Signature *

Clear
AAA FTS Coordinator Signature Date *

Month Day Year
Date
Should be Empty:

Request for Financial Transaction Services Payment - Aging Waiver

Chore Services

Environmental Accessibility Adaptations

Supplemental Meals

Specialized Medical Equipment/Supplies/Assistive Technology

Community Living Services