FMS Pay — Virtual Card Request & Agreement

To enhance our participants' access to various services, FMS Pay is pleased to offer the issuance of a virtual credit card in appropriate circumstances. Virtual cards are primarily intended for ongoing service arrangements. Common scenarios: monthly gym memberships; monthly cell phone or internet plans; registration or one-time payments for activities such as YMCA memberships, swimming lessons, or karate classes; and situations requiring access to the client's private account, preventing the need to share login credentials (e.g., online tutoring registration). To mitigate misuse and limit fraud exposure, each virtual card is linked to a specific merchant — for instance, a card requested for a monthly AT&T cell phone bill will only authorize transactions with AT&T.

What is this virtual card for?

⚠ Virtual cards cannot be issued for physical items — these are purchased directly by FMS Pay. Please use our One-Time Purchase Request form instead; this form cannot be submitted for physical items.

Client Name

UCI #

Your Regional Center client number (also called UCI). Ask your case manager if you're not sure.

Regional Center

Contact email

We'll use this if we have questions about your request.

Contact phone

Please enter a valid phone number.Format: (000) 000-0000.

Merchant Name

The card will ONLY work at this merchant.

Product/Service Requested

Website URL

Link to the specific merchant website.

Amount

Per charge — e.g., $45.99

Frequency

If Other, please describe the frequency

Invoice / Contract / Backup Documentation

Attach the invoice, contract, registration page, or other documentation supporting this request, if available. If the business provides the receipt after the transaction (e.g., a gym membership agreement), you can skip this — receipts must still be emailed to connect@fmspay.com after the transaction.

Spending plan & IPP alignment

In plain words: this request must match your spending-plan and your IPP goals, or it will be declined.

Paying a service provider with a virtual card does not exempt that provider from the qualification and verification requirements of California's Self-Determination Program. Appendix C of the approved 1915(c) waiver (CA.1166.R01.00) sets the license, certification, and other standards required for each waiver service, and names the FMS and the participant as the parties responsible for verifying that a provider meets them — upon selection and annually thereafter through the IPP process. The method of payment (virtual card, ACH, check) has no bearing on this requirement. Before a virtual card can be issued to a service provider, FMS Pay must have a complete vendor file on record, which may include: a valid business license; the professional license or certification required for that service under Appendix C; a signed Appendix C Confirmation Form where the service carries no specific licensure or certification requirement; and a cleared criminal background check where the provider furnishes direct personal care (W&IC sections 4689.2 to 4689.6). The card cannot be issued until verification is complete. Vendor qualification requirements: https://myfmspay.zohodesk.com/portal/en/kb/articles/vendor-qualifications

In plain words: paying by card does not skip the vendor check, even if other FMS skip it. If a person or business is providing a service, they still have to be qualified and have a vendor file with FMS Pay before the card is turned on.

I understand that the service provider must still be verified and qualified under Medicaid Waiver Appendix C, regardless of being paid by virtual card.

Receipts commitment

I commit to submitting accurate and timely receipts for all transactions to connect@fmspay.com, clearly indicating the services or support received and their associated costs. I understand that failure to provide a receipt or any misuse of the virtual card will result in the immediate termination of the card and may restrict my ability to request virtual cards in the future, and that any misuse will be reported to the Regional Center's case management team and the Department of Developmental Services (DDS).

In plain words: send your receipts to connect@fmspay.com every time you use the card. No receipts, or wrong use of the card, means the card is turned off.

Cancellations & card termination

If I am requesting an ongoing monthly amount, I agree to promptly inform FMS Pay should I wish to cancel the card or alter the authorized amount. FMS Pay will not be liable for any charges incurred if I fail to notify the company in a timely manner regarding cancellations — for example, if I enroll in a monthly gym membership and neglect to cancel. I understand FMS Pay reserves the right to terminate the virtual card if there are insufficient funds available in the service code or if the budget year concludes without a new spending plan submission.

In plain words: if you stop using a monthly service (like a gym), tell FMS Pay right away so we can stop the payments.

Charges, refunds & liability

All charges on the card will be deducted from the participant's spending plan. The virtual card functions as a credit card, not a prepaid card. Any refunds processed will be allocated back to the spending plan; however, frequent returns may necessitate termination of the virtual card due to difficulties issuing refunds to the Regional Center. All charges are expected to be final and refunds should be considered rare; in certain cases the merchant may be unable to issue a refund, particularly after the virtual card has been terminated. FMS Pay does not endorse specific goods or services and offers no guarantees, warranties, or assurances of customer satisfaction; all purchases may be final subject to the merchant's return policies, and FMS Pay cannot be held accountable for buyer's remorse, dissatisfaction, or defective, damaged, or misadvertised products. FMS Pay is not responsible for circumstances beyond its control, such as the merchant's failure to deliver, delivery of incorrect products or services, or loss or theft during shipping, including porch piracy. I confirm I have provided FMS Pay with my accurate and valid shipping address.

In plain words: charges come out of your spending-plan. Purchases are final — Regional Centers cannot process refunds. FMS Pay is not responsible if a product or service disappoints or a delivery goes wrong.

Printed Name

Signature

Date Signed

Date

FMS Pay — Virtual Card Request & Agreement

Client Information

Virtual Card Request Specifics

Disclosures & Acknowledgements