Portage FSSP Services Request Form

Family Support Services Request Form

For use by eligible families and parties acting at the request of eligible families, to register requests for services funded through the Portage County Board of Developmental Disabilities Family Support Services Program.

ALL REQUESTS MUST BE PRE-APPROVED BEFORE MAKING ANY PURCHASES/REIMBURSEMENTS
Full Name of the family making request:*
First and Last Name
First Name of person served:*
Last Name of person served:*
Date of Birth of person served:*

MonthDayYear
Date
Age:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address:*

Confirmation Emailexample@example.com
Phone Number:*
Please enter a valid phone number.
Diagnosis*
Family Co-Pay (enter 0 if no co-pay)*
Does the individual served have a waiver?*

YesNo
Does the individual served have an IEP?*

YesNo
Type of Service being requested (check one):*

DiapersRecreational Therapies/FamilyTrainingHome ModificationDietary ItemsCamp AssistanceEquipment
Please describe, specifically, what item/service you wish to purchase with FSSP assistance (include brand name, model, color, etc., as applicable:)*

0/200
Copy and Paste the website link to item requested (if applicable) - This may help us process your request quicker:
Please click below to upload OR take a picture of your backup documentation, such as prescriptions, doctor's recommendations, images of item, etc. 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
If applicable, what is the type of unit requested?
Cases, packs, hours, sessions, etc.
Approximately how much does one unit cost. ?*
Dollar amount per case, pack, hour, session, etc.
How many units do you need?*
Enter # being requested
Approximately how much is the shipping/handling cost, if any?
Total approximate cost (auto calculated based on information provided above):
Total approximate cost:*
Do you wish your family to be reimbursed for approved expenses?*

YesNo
Do you wish FSSP to pay the supplier/service provider directly?*

YesNo
Name of supplier/service provider you wish FSSP to pay directly (if you are not sure, enter "unknown":*
Address of supplier/service provider to be paid (if NEON will be issuing a check):

Street Address

Street Address Line 2

CityState

Zip Code
How will the item/service you are interested in help you provide care or meet the special needs of the person served?*

0/70
Did you discuss your need with the SSA/Service Coordinator/Service Planning Team before requesting FSSP assistance?*

YesNo
Name of person your request was discussed with:*
If "Yes", please list any alternatives or discussions that were described and follow-up action that was taken:*

0/70
Signature of person making request:*

Clear
Date

YearMonthDay
Date
Should be Empty: