Family and Child Service of Schenectady, Inc. 246 Union Street Schenectady, NY (518)

Transcription

1 Family and Child Service of Schenectady, Inc. 246 Union Street Schenectady, NY (518) Family Support Services Family Reimbursement Grant Application Family and Child Service of Schenectady, Inc. provides Family Support Services grants to consumers diagnosed with a developmental disability, who reside with a family member in Schenectady, Albany, Saratoga, Schoharie, and Rensselaer Counties. Grants are available for the purpose of goods and services, respite reimbursement, recreation and emergency funding. Grants for goods and services, respite reimbursement and recreation are distributed quarterly in the months of February, April, August, and October. Every quarter a grant committee, composed of family members related to a developmentally disabled consumer, reviews the requests and determines the approval or non-approval of grants. The committee reviews these requests on an anonymous basis. Decisions are based on the following: Waiver, Medicaid or private insurance funding denial, the need for the grant, previous grants received by the family, and how the grant will improve the individual s quality of life. Requests for emergency funding are reviewed as they are received and are not limited to quarterly reviews After the grant committee has met the agency will contact you via mail as to the decision of the committee. Letters of approval or non-approval will be generated within one month of the meeting date. Emergency approval or non-approvals will be generated within approximately one (1) to (2) weeks. Unfortunately we are not always able to approve all requests. If a gift card is approved for clothes, household items or food the agency requires that the Medicaid Service Coordinator accompanies the family. Receipts of any items purchased through FSS grant funding must be submitted to the agency no later than one (1) month after the approval date. Subsequent grants may not be considered if receipts have not been submitted. Thank you for applying to our agency for a FSS grant. Please contact Toni Wakefield at (518) or twakefield@familyandchildservice.com with any questions or assistance needed in completing the application. Revised 12/11

2 Family and Child Service of Schenectady FSS Grant Application Check List (PLEASE RETURN WITH COMPLETED APPLICATION) CONSUMER /MSC INFORMATION COMPLETE (MEDICAID, TABS, PHONE # S, ADDRESS ETC.) SIGNATURE OF CONSUMER OR PARENT/GUARDIAN (REQUIRED TO PROCESS) DDSO ELIGIBILITY DOCUMENTATION JUSTIFICATION FOR REQUEST PAID DOCUMENTATION (RECEIPT) IF REQUESTING REIMBURSEMENT FOR AN ITEM ALREADY PURCHASED. (3) ESTIMATES (IF APPLICABLE) INCLUDING VENDOR NAME & MAILING ADDRESS DENIAL LETTER FROM MEDICAID, PRIVATE INSURANCE OR WAIVER SERVICE (ENVIORNMENTAL MODIFICATION OF ADAPTIVE TECHNOLOGY REQUIRED (IF APPLICABLE) NAME & PHONE NUMBER OF PROVIDER IF REQUESTING A SERVICE SUCH AS RESPITE REIMBURSEMENT, PIANO LESSONS, MUSIC THERAPY, TUTORING, ETC. FINAL SHUT OFF OR EVICTION NOTICE (WITH CONTACT INFORMATION) REQUIRED FOR ASSISTANCE WITH POWER, TELEPHONE OR RENT, ETC. EMERGENCY REQUEST Application needs to be legible and completed in full to be submitted for review. The MSC of the applicant will be notified of incomplete applications at the convenience of the Director of Family Support Services. Signature of person completing application Agency _ ext. Phone _ E mail address

3 Office Use Only: Category: Name: FSS REIMBURSEMENT GRANT APPLICATION 246 Union Street Schenectady, NY (518) Fax: or Office Use Only # QTR. YR. of Application: Application Completed By: APPROVED NOT APPROVED CK REQUEST Name of Applicant: Individual with disability Address: Street City State Zip Code Phone Number: Gender (circle one): Male / Female of Birth: / / Medicaid Number: Tabs Number:- Persons Living in the Home: Parent/Guardian (First, Last) Home Phone Work/Cell Phone Parent/Guardian (First, Last) Home Phone Work/Cell Phone The total number of siblings, under the age of 18 residing in the same residence (Do not include applicant) = Disability Information: Please indicate all disabilities by checking all that apply: Mental Retardation Cerebral Palsy Epilepsy Autism Down Syndrome Visually Impaired Spina Bifida TBI Hearing Impaired Other: Any other medical concerns (shunts, pacemakers, et cetera): Adaptive equipment already used (eye glasses, hearing aids, AFOs, et cetera): Medicaid Service Coordination Information: Name: Phone: Address: Agency Name: Agency Address: Street City State Zip Code 1

4 Please indicate any major shift in the family dynamic within the past year that has caused undue hardship (i.e. loss of a job, hospitalization, death in the family, et cetera): Other Grant Information: Please list all grants that the applicant has received since the beginning of the current calendar year: Item(s) Received Agency Name Award amount Received Item(s) Received Agency Name Award amount Received Item(s) Received Agency Name Award amount Received Item(s) Received Agency Name Award amount Received Is the applicant currently applying elsewhere with this same request? Yes No Agency Name Agency Phone # Requested Has the applicant applied to other agencies with this same request in the past and been denied? Yes No Agency Name Reason for Denial Income Information: Wage Income (gross) per Year: Other sources of income not including working wages (SSI, SSD, Child Support, et cetera): ) SSI/SSD: per month Child Support: per month Other: per month Do you: Own Rent Other What additional expenses are related to the applicant s disability: What health insurance do you/your family currently have? Consumer Waiver Information: Is the applicant currently enrolled in Medicaid Waiver? Yes No Pending Please list any HCBS (Community Habilitation, Respite, etc.) the applicant is currently receiving or authorized to receive. Service Agency Name Agency Phone # Service Agency Name Agency Phone # Service Agency Name Agency Phone # Please list any DSS Services received by applicant (food stamps, HUD, et cetera): 2

5 Current Request: Please list each item requested including requests for respite reimbursement. *A minimum of three estimates is required for applicable items (furniture, adaptive equipment, appliances, etc.) *A denial letter from Medicaid, private insurance or Waiver service is also required for any applicable items (adaptive equipment, environmental modification, medical procedures, etc.) Grant Request: EMERGENCY REQUEST: What amount (or percentage) is the Family able to contribute? Justification for the requested item(s) (please attach an additional page if necessary): Amount Requested Please complete this section if you are requesting respite reimbursement or a service provided by a qualified provider. All of the following information is mandatory: Requests will not be considered without the name, address and phone number of the individual able to provide the service Name (Respite Worker) Phone Address AND /OR Name (Service Provider) (Service) Phone Address If the applicant is authorized to receive Respite or Community Habilitation services please explain why respite funding is being requested: Signatures (required): Applicant Parent/Guardian Medicaid Service Coordinator 3

6 Family Support Services Grant/Reimbursement Program Guidelines For Family and Child Service of Schenectady The total amount of FSS respite reimbursement grant funding approved per consumer, per calendar year is (as funds are available). The award amount will be limited to no higher than increments. A second and/or third request for an additional (as funds are available) will only be considered after all previous respite reimbursement vouchers have been submitted for payment and have been approved by the Director of FSS. Respite reimbursement will only be considered in the 1 st, 2 nd, and 3 rd quarter of the year. A new grant application will need to be submitted for each request. Priority will be given to consumers who are not approved to receive waiver respite and/or community habilitation services. The Agency will only reimburse up to per hour of respite service. Requests for services such as, but not limited to, music therapy, therapeutic horseback riding, sign language, piano lessons, recreational activities, etc. will be awarded one (1) time per calendar year. These will only be considered in the 1 st, 2 nd, and 3 rd quarter of the year. Requests for therapeutic/technological services must have a physician/therapist justification or script and a documented denial from Medicaid that they will not cover the service. Requests for clothing or other related items must be related to the consumer s disability. (E.g. ripping, tearing, and soiling of clothing.etc.) Eligible applicants may apply for this two (2) times per calendar year. The maximum amount that could be awarded per calendar year will not exceed The award amount will be limited to no higher than increments (as funds are available). Requests for food must be related to the consumer s disability. (Special diet, gluten free. Otherwise not covered by Medicaid). Eligible applicants may apply for this two (2) times per calendar year. The maximum amount that could be awarded per calendar year will not exceed The award amount will be limited to no higher than increments (as funds are available). If requesting reimbursement of an item already purchased an original paid receipt must accompany grant request. Consumers whose eligibility (provisional) has lapsed will be considered for grant awards if justification is submitted that eligibility is in the process of being worked on for re-determination. Consumers must live as part of a natural family unit in their own family home to be eligible for grants. Families of one person are not eligible. Grant applications must be completely filled out and legible. All information requested (as applicable) on the FSS grant application check list must be included. Request for Emergency funds: Eligible individual must demonstrate urgent need (imminent eviction or cancellation of utilities: electric and/or heating source). Verify impending eviction or termination of services from the appropriate vendor. Current utility statement must be submitted. Verify that all other payment options have been exhausted (i.e. HEAP, budget plans, DSS, etc.) Rental assistance is limited to one (1) month of rent. Security payment will not be funded. The name, address and phone number of the property owner must be included with the request. Families of low income will be prioritized. Individuals will only be eligible to receive emergency funding one (1) time per calendar year, with the maximum amount determined by the grant committee. Emergency grant requests can be submitted at any time throughout the year. They will be reviewed by the committee as they are received and a determination will be made approximately within a one (1) to two (2) week period. Notification of the approval or non-approval will be made to the individual and the MSC. Emergency grant requests are to be submitted on the FCSS family reimbursement grant application. The request needs to be identified under EMERGENCY REQUEST which is located on page 3 of the application Revised 12//11

7 2012 FSS GRANT COMMITTEE MEETING SCHEDULE FOR FAMILY & CHILD SERVICE OF SCHENECTADY FEBRUARY 1, 2012 (GRANT COMMITTEE MEETING) APPLICATIONS DUE BY JANUARY 18, 2012 APRIL 25, 2012 (GRANT COMMITTEE MEETING) APPLICATIONS DUE BY APRIL 11, 2012 AUGUST 1, 2012 (GRANT COMMITTEE MEETING) APPLICATIONS DUE BY JULY 18, 2012 OCTOBER 24, 2012 (GRANT COMMITTEE MEETING) APPLICATIONS DUE BY OCTOBER 10, 2012 FSS GRANT APPLICATIONS RECEIVED AFTER THE QUARTERLY DUE DATE WILL BE SUBMITTED FOR THE FOLLOWING QUARTERLY COMMITTEE MEETING DATE. PLEASE CONTACT TONI OR twakefield@familyandchildservice.com