Advanced Health Flexible Funding

Flexible "Flex Funding" Services Request Form

Member Information

Member needing request is a minor.
Street Address:

Mailing Address (if different):

Requesting Party Information

Request Details



*vendor is not guaranteed
Request Category:
Is member established with PCP (Primary Care Provider)?
Yes:  No: 
Sources of Income: (check all that apply)
Employment
SSI/SSD
SNAP
TANF
Other
Do you have a treatment/care plan and sustainability plan to upload below?
If this item or service is a covered benefit, a copy of the denial must be included.
Choose Select Files at the bottom of this page to upload.
Yes:  No:  		Please check all resources that have been attempted, as Flex Fund is payor of last resort:
APD (if member has a case manager)
ORCCA
New Eyes (Eye exam, Glasses)
Access Wireless
BCB
HRSN (Climate, Housing, Nutrition)
Employment Programs
Made payment arrangements (Utilities or Rent)
Upload all Care Plans, Treatment Plans, and other Supporting Documents here: