Portage County DD Reimbursement/Payment Form

Portage County DD Family Support Services Program (FSSP)/ NEON

REIMBURSEMENT/PAYMENT REQUEST FORM
If currently enrolled in Portage County DD FSSP, reimbursements/payments can be provided for many goods and services not otherwise funded by other sources and as related to the individual’s diagnosis. If you would like to view the current FSSP stipulations, please click here to go to NEON's website. Scroll down to "Portage County" and then click on "Portage Forms". Please contact NEON with any questions at PortageFSS@neoncog.org or 234-254-5874.

Please note: To take pictures of your receipts, you must currently be completing this form on a device capable of taking pictures. If your receipts are located on the device you are currently using, you will be able to upload them.
Are you requesting payment or reimbursement for respite?*

YesNo
Is your respite provider a family member who lives in the same home as the individual receiving respite care?*

YesNo
STOP HERE. Beginning 1/1/26, a family member who lives in the same home as the individual receiving respite care cannot provide respite care for that individual.
- First Name of Child/Individual enrolled in FSSP*
- Last Name of Child/Individual enrolled in FSSP*
- Date of Birth of Child/Individual enrolled in FSSP*
  
  MonthDayYear
  Date
- Parent/Guardian First NameParent/Guardian Last Name
- Address*
  
  Street Address (Include Apt #, Up/down, PO Box, etc)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Will the check be made payable to the Parent/Guardian listed above?:*
  
  YesNo
- Please list the name of the individual to be paid (full name of person the check should be made payable to):*
  
  First NameLast Name
- Address where check is to be delivered:*
  
  Same as Parent/GuardianOther
- Address where check is to be delivered:*
  
  Street Address - Include Apt #, PO Box, etc.
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian E-mail*
  example@example.com
- Parent/Guardian Phone *
- Please select all categories you are submitting receipts/invoices for:*
  
  RespiteIncontinence Supplies (requires a prescription submitted to NEON annually)CampSpecial Diet (requires a prescription submitted to NEON annually)Counseling/Therapy/EducationEquipmentOther (ie. memberships, guardianship fees, etc)
- Beginning 1/1/26, a family member who lives in the home cannot provide respite. If you have not already submitted proof of residency for your provider, please upload OR take a picture of your provider's Driver's License/State ID or current utility bill. If you do not have this available, you can submit it later but your request will be on hold until we receive this documentation:
  
  Cancelof
- Respite Total:*
- Incontinence Supplies Total:*
- Camp Total:*
- Special Diet Total:*
- Counseling/Therapy/Education Total:*
- Equipment Total:*
- Other (ie. memberships, guardianship fees) Total:*
- Total Amount:
  This amount will auto calculate
- 1Total Amount:
- If uploading a store receipt, the date of purchase MUST be included in the photo. Any items you wish to be reimbursed for must be clearly marked on the receipt.
  
  If uploading counseling/therapy/education receipts, the receipts must include the date(s) of service and the individual's name who is receiving Family Supports funding.
- Please click below to upload OR take a picture of your receipt(s)/invoices. There is no limit to the number of uploads/pictures. To take a picture, you must currently be completing this form on a device capable of taking pictures: *
  
  Cancelof
- I understand that I must CLEARLY IDENTIFY which item(s) on the receipt(s) being submitted are to reimbursed (if applicable)
- Additional Comments (if any):
  
  0/100
- Signature:*
  
  Clear
- Submission Date*
  
  YearMonthDay
  Date
Should be Empty:

Portage County DD Family Support Services Program (FSSP)/ NEON