Housekeeping Pre-Authorization Form

Housekeeping Pre-Authorization Form

Please allow 2-4 weeks for pre-determination of benefit. The SBHASA Board will review all requests; all expenses are subject to AGLC approval.
Housekeeping Services (pre-approval basis only) may be utilized to improve the quality of life for individuals living independently with Spina Bifida and/or related Hydrocephalus and to assist with maintaining safety within the member’s home, particularly post surgery.
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Name of person with Spina Bifida whom services are requested for:*

First NameLast Name
Date of Birth for person with Spina Bifida whom services are requested for:*

MonthDayYear
Date
Please provide details explaining why you are requesting pre-approval for housekeeping (please include as much information as possible; ample space is provided below).*
How frequent do you anticipate Housekeeping needs?:*

MonthDayYear
Date
All benefits, including those that are pre-authorized, are subject to SBHASA funding support guidelines.
- Applications must meet volunteer requirements (ie Sliding Scale Point System).
- Housekeeping reimbursement rate will be based on a maximum of 24 hrs per calendar year at a rate of $25 per hour.
- The provider of Housekeeping services must be a verifiable and legitimate professional cleaning company. (SBHASA reserves the right to confirm business registration, insurance, and regulatory compliance.)
The receipt must include:
- Permanent home address of the individual with SB/H where the service will be rendered.
- The service provider’s name, address, and phone number.
- Confirmation of payment (e.g., a screenshot or copy of a bank or credit card statement). Cash payments are not accepted, SBHASA will not pay the provider directly.
- Moving costs are not covered by SBHASA.
By signing below, you confirm you have read and understand the above guidelines and criteria for invoicing:*

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