• Request for Financial Transaction Services Payment - New Choices

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  • Assistive Technology Devices

    HCPCS Code T2028
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  • Environmental Accessibility Adaptations - Home Modifications

    HCPCS Code S5165
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  • Environmental Accessibility Adaptations - Vehicle Modifications

    HCPCS Code T2039
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  • Community Living Services

    HCPCS Code T2038
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  • Specialized Medical Equipment

    HCPCS Code T2029
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  • Chore Services

    HCPCS Code S5120
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  • Non-medical Transportation - Public Transit Pass

    HCPCS Code T2004
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  • 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.

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