Advanced Health Flexible Funding

Flexible "Flex Funding" Services Request Form

Request Type

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: 
Common Resources (check all that apply)
APD (if member has a case manager)
SAFE Project or OASIS Shelter (Domestic Violence)
Lions Club, New Eyes (Eye exam, Glasses)
Active Living Program
Area Agency on Aging (AAA)
Affordable Connectivity Program (cell phones and internet)
Supporting Documents: