Elevance Health West Virginia Flex Fund Request Form
Elevance Staff Requestor Information
Requestor First and Last Name
*
First Name
Last Name
Requestor Phone Number
Please enter a valid phone number.
Requestor Email
*
Confirmation Email
Confirmation Email - a copy of this request will be sent to this email address
Member Information
Member ID Number
*
Member's First and Last Name:
*
First Name
Last Name
Member Phone Number
Please enter a valid phone number.
Member Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Medicaid ID:
Member's Date of Birth:
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Multiracial
Other
Not Identified
County
*
Region
Payment Request Details
Public Transportation
Do you have an entry for Public Transportation?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Please Select a Specific Expense
Bus Pass
Lyft/Uber
Bus Pass + Lyft/Uber
Carpooling Costs
Other - Requestor Provide Additional Details
Total Amount
Company/Vendor Name
Lyft/Uber Amount
Lyft or Uber
Lyft
Uber
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Technology Needs
Do you have an entry for Technology Needs?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Please Select a Specific Expense
Cell Phone Bill Payment
Increased Internet
Upgrade to a Laptop
Other - Requestor Provide Additional Detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
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Vehicle Maintenance/Repair
Do you have an entry for Vehicle Maintenance/Repair?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Please Select a Specific Expense
Vehicle Repairs
Registrations/Driver's Education
Maintenance - (i.e. New Tires)
Other - Requestor Provide Additional Detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Clothing/Professional Appearance
Do you have an entry for Clothing/Professional Appearance?
Yes
Please Select a Specific Expense
Clothing for Interviews, Work Clothing, Uniform
Haircare
Shoes
Other - Requestor Provide Additional Detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Barriers to Accessing Employment, Education & Training
Do you have an entry for Barriers to Accessing Employment, Education & Training?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Please Select a Specific Expense
Education/Testing Fees
Certifications
Birth Certificate Copies
Driver's License
Other - Requestor Provide Additional Detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
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Housing Flex Fund
Do you have an entry for Housing Flex Fund?
Yes
Please Select a Specific Expense
Short Term Emergency Housing Needs
Security Deposit
Rental Assistance
Rental Arrears
Utility Deposit
Utility Arrears
Move-In Items
Moving Fees
Other - Requestor Provide Additional Detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
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Other
Do you have an entry for an Other?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Housing Flex Fund
Please Select a Specific Expense
Food?
Other - Requester provide additional detail
Total Amount
Company/Vendor Name
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
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Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Please Select a Specific Fund for the Below Expense
SDOH Flex Fund
Employment Flex Fund
Housing Flex Fund
Expense Category
Please Select
Public Transportation
Technology Needs
Vehicle Maintenance/Repair
Clothing/Professional Appearance
Barriers to Accessing Employment, Education & Training
Housing Flex Fund
Other - Provide Additional Detail
Public Transportation (SDOH or Employment)
Bus Pass
Lyft/Uber
Bus Pass + Lyft/Uber
Carpooling Costs
Other - Provide Additional Detail
Technology Needs (SDOH or Employment)
Cell Phone Bill Payments
Increased Internet
Upgrade to a Laptop
Other - Provide Additional Detail
Vehicle Maintenance/Repair (SDOH or Employment)
Vehicle Repair
Registration/Driver's License/Driver's Education
Maintenance - (i.e. New Tires)
Other - Provide Additional Details
Clothing/Professional Appearance (Employment)
Clothing for Interviews, Work Clothing, Uniform
Haircare
Shoes
Other - Provide Additional Detail
Barriers to Accessing Employment, Education & Training (SDOH or Employment)
Education/Testing Fees
Certifications
Birth Certificate Copies
Driver's License
Other - Provide Additional Detail
Housing Flex Fund
Short Term Emergency Housing Needs
Security Deposit
Rental Assistance
Rental Arrears
Utility Deposit
Utility Arrears
Move-In Items
Moving Fees
Other - Provide Additional Detail
Other (SDOH, Employment or Housing)
Food
Other - Provide Additional Detail
Total Amount
Company/Vendor Name
Lyft/Uber Amount
Lyft or Uber
Lyft
Uber
Company/Vendor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Vendor Contact Name
First Name
Last Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Additional Expense Approval
The Total Dollar Amount of This Request Is -
*
$0 - $1,000.00
$1,000.01 - $2,500.00 (Requires Manager Approval)
$2,500.01 + (Requires Program Manager Approval)
File Upload
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Please upload a copy of the Anthem Internal Approval Form
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Elevance Reviewer / Approving Staff Name
*
First Name
Last Name
Title
*
Elevance Approving Staff Signature
*
Clear
Elevance Staff Signature/Submission Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: