Amerigroup Tennessee LTSS Employment Flex Fund Request Form
Amerigroup 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 Identity
*
Please Select
Blank/Null
Female
Gender X
Male
Nonbinary
Transgender Female
Transgender Male
Other
Ethnic Origin
*
Please Select
African
African American
American Indian
Asian
Caucasian
Eastern European
Hispanic
Middle Eastern
Native American
Northern European
Russian
Western European
Not Identified
Other
Payment Request Details
Public Transportation
Do you have an entry for Public Transportation?
Yes
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 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
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Vehicle Maintenance/Repair
Do you have an entry for Vehicle Maintenance/Repair?
Yes
Please Select a Specific Expense
Vehicle Repairs
Registration/Driver's License/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 Expense
Education/Testing Fees
Certifications
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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Rapid Financial Support
Do you have an entry for Rapid Financial Support?
Yes
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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Other
Do you have an entry for an Other?
Yes - Requestor Provide Addtional 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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Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Expense Category
Please Select
Public Transportation
Technology Needs
Vehicle Maintenance/Repair
Clothing/Professional Appearance
Barriers to Accessing Employment, Education & Training
Rapid Financial Support
Other - Provide Additional Detail
Public Transportation
Bus Pass
Lyft/Uber
Bus Pass + Lyft/Uber
Carpooling Costs
Other - Provide Additional Detail
Technology Needs
Cell Phone Bill Payments
Increased Internet
Upgrade to a Laptop
Other - Provide Additional Detail
Vehicle Maintenance/Repair
Vehicle Repair
Registration/Driver's License/Driver's Education
Maintenance - (i.e. New Tires)
Other - Provide Additional Details
Clothing/Professional Appearance
Clothing for Interviews, Work Clothing, Uniform
Haircare
Shoes
Other - Provide Additional Detail
Barriers to Accessing Employment, Education & Training
Education/Testing Fees
Certifications
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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Overnight Payment Option
There is an additional fee for each overnighted payment.
Overnight Payment Required?
Yes
Please Overnight The Payment For -
Public Transportation
Technology Needs
Vehicle Maintenance/Repair
Clothing/Professional Appearance
Barriers to Accessing Employment, Education & Training
Rapid Financial Support
Other
Amerigroup Reviewer / Approving Staff Name
*
First Name
Last Name
Title
*
Amerigroup Approving Staff Signature
*
Amerigroup Staff Signature/Submission Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: