Elevance Health Community Connect Flex Fund Request Form
Select your State
Please Select
Colorado
Kentucky
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
A copy of this submission will be sent to this email address
Please enter a corporate email address from an approved email domain.
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
County of Medicaid Coverage
*
Region
Homeless Status (Please check one)
*
At Risk of Homelessness
Experiencing Homelessness
Security Deposit
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Security Deposit?
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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Rental Assistance
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Assistance?
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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Rental Arrears
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Rental Arrears?
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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Utility Deposit
Do you have an entry for Utility Deposit?
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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Utility Arrears
Do you have an entry for Utility Arrears?
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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Move-In Items
Do you have an entry for Move-In Items?
Yes
Total Amount
Company/Vendor/Website
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 / Web Links (Word Doc)
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Moving Fees
A COMPLETED IRS FORM W-9 IS REQUIRED FOR THIS SECTION
Do you have an entry for Moving Fees?
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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Public Transportation
Do you have an entry for Public Transportation?
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 Other?
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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Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Expense Category
Please Select
Clothing
Employment Needs
Food
Move-In Items
Moving Fees (W-9 REQUIRED)
Other
Public Transportation
Rental Arrears (W-9 REQUIRED)
Rental Assistance (W-9 REQUIRED)
Security Deposit (W-9 REQUIRED)
Utility Arrears
Utility Deposit
Vehicle Maintenance/Repair
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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Elevance Reviewer / Approving Staff Name
*
First Name
Last Name
Title
*
Elevance Approving Staff Signature
*
Elevance Staff Signature/Submission Date
*
-
Month
-
Day
Year
Date
Submit
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