Portage County DD Reimbursement 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 2024 FSSP stipulations, please click here to go to NEON's website. Scroll down to "Portage County" and then click on "Portage Forms".

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.
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)
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