Respite Pre-Authorization Form

Respite 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.
Respite Services (pre-approval basis only) may be utilized to assist with the care for the individual living with Spina Bifida and/or related Hydrocephalus. The benefit is intended to be used for any outsourced respite not covered by FSCD, PDD, or any other source (receipts required).
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 Respite (please include as much information as possible; ample space is provided below).*
What is the anticipated frequency of service?:*

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).
- Applicant must be registered with FSCD/PDD (if on a waiting list, please provide confirmation of application).
- Applicant must provide confirmation of FSCD/PDD coverage being depleted.
- Respite reimbursement rate will be based on a maximum of 36 hrs per calendar year at a rate of $20 per hour.
- The provider of Respite services must be a verifiable and legitimate caregiver (not residing in the permanent household).
The receipt must include:
- 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.
By signing below, you confirm you have read and understand the above guidelines and criteria for invoicing:*

Powered by Jotform SignClear
Should be Empty: