Request for Financial Transaction Services Payment

Request for Financial Transaction Services Payment - New Choices
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 Gender (For Billing) *

Female Male
Participant's Date of Birth: *

Month Day Year
Date
Case Management Agency: *
Date of Request: *

Month Day Year
Date
Email *

Confirmation Email example@example.com
Approval by the New Choices Waiver Program Office is required for all FTS requests via the care plan process. Has this request, including reimbursement above the MAR if applicable, been approved on the care plan? *

Yes No
Date of formal care plan approval *

Month Day Year
Date
Is this client a new enrollment/re-enrollment *

Yes No
If yes, provide the (re)enrollment date:

Month Day Year
Do not send until client has actually moved onto the program
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
Assistive Technology Devices

HCPCS Code T2028
Do you have an entry for this section? (HCPCS Code T2028)

Yes
Service Code Start Date

Month Day Year
T2028 Start Date on Care Plan
Service Code End Date

Month Day Year
T2028 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
Environmental Accessibility Adaptations - Home Modifications

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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
Environmental Accessibility Adaptations - Vehicle Modifications

HCPCS Code T2039
Do you have an entry for this section? (HCPCS Code T2039)

Yes
Service Code Start Date

Month Day Year
T2039 Start Date on Care Plan
Service Code End Date

Month Day Year
T2039 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
Specialized Medical Equipment

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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancel of
Non-medical Transportation - Public Transit Pass

HCPCS Code T2004
Do you have an entry for this section? (HCPCS Code T2004)

Yes
Service Code Start Date

Month Day Year
T2004 Start Date on Care Plan
Service Code End Date

Month Day Year
T2004 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
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.
CMA FTS Coordinator Name (Print) *

First Name Last Name
CMA FTS Coordinator Signature *

Clear
CMA FTS Coordinator Signature Date *

Month Day Year
Date
Should be Empty:

Request for Financial Transaction Services Payment - New Choices

Assistive Technology Devices

Environmental Accessibility Adaptations - Home Modifications

Environmental Accessibility Adaptations - Vehicle Modifications

Community Living Services

Specialized Medical Equipment

Chore Services

Non-medical Transportation - Public Transit Pass