Advanced Health Flexible Funding

Flexible "Flex Funding" Services Request Form

Request Type

Urgent?
No:  Yes: 		Do you have an ICC Coordinator?
Yes:  No: 

Member Information
Street Address:

Mailing Address (if different):

Requesting Party Information

Request Details




Request Category:
Do you have a treatment/care plan and sustainability plan?
Yes:  No:  		Resources Attempted (check all that apply)
APD (if member has a case manager)
ORCCA
SAFE Project or OASIS Shelter (Domestic Violence)
Lions Club, New Eyes (Eye exam, Glasses)
Active Living Program
Area Agency on Aging (AAA)
UniteUs
Supporting Documents: