MSFS of IA Elevance Health Employment Flex Fund Request Form

MSFS of IA Elevance Health Employment Flex Fund Request Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Elevance Staff Requestor Information
Requestor First and Last Name*

First NameLast Name
Requestor Phone Number
Please enter a valid phone number.
Requestor Email*

Confirmation EmailConfirmation Email - a copy of this request will be sent to this email address
Member Information
Member ID Number*
Member's First and Last Name:*

First NameLast Name
Member Phone Number
Please enter a valid phone number.
Member Address*

Street Address

Street Address Line 2

CityState

Zip Code
Member's Medicaid ID:
Member's Date of Birth:*

MonthDayYear
Date
Gender Identity*
Race*
Payment Request Details
Public Transportation
Do you have an entry for Public Transportation?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Technology Needs
Do you have an entry for Technology Needs?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Vehicle Maintenance/Repair
Do you have an entry for Vehicle Maintenance/Repair?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Clothing/Professional Appearance
Do you have an entry for Clothing/Professional Appearance?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Barriers to Accessing Employment, Education & Training
Do you have an entry for Barriers to Accessing Employment, Education & Training?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Rapid Financial Support
Do you have an entry for Rapid Financial Support?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
One Time/Time Limited Expenses
Do you have an entry for a One Time/Time Limited Expense?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Other
Do you have an entry for Other?

Yes
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Additional Expense(s)
Do you have an entry for an Additional Expense?

Yes
Expense Category
Total Amount
Company/Vendor Name
Company/Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Company/Vendor Contact Name

First NameLast Name
Company/Vendor Contact Email
example@example.com
Company/Vendor Contact Phone Number
Please enter a valid phone number.
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form

Cancelof
Overnight Payment Option

There is an additional fee for each overnighted payment.
Overnight Payment Required?

Yes
Please Overnight The Payment For -

Public TransportationTechnology NeedsVehicle Maintenance/RepairClothing/Professional AppearanceBarriers to Accessing Employment, Education & TrainingRapid Financial SupportOne Time/Time Limited ExpensesOther
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Elevance Reviewer / Approving Staff Name*

First NameLast Name
Title*
Elevance Approving Staff Signature*

Clear
Elevance Staff Signature/Submission Date*

MonthDayYear
Date
Should be Empty:

MSFS of IA Elevance Health Employment Flex Fund Request Form

Elevance Staff Requestor Information

Member Information

Payment Request Details

Public Transportation

Technology Needs

Vehicle Maintenance/Repair

Clothing/Professional Appearance

Barriers to Accessing Employment, Education & Training

Rapid Financial Support

One Time/Time Limited Expenses

Other

Additional Expense(s)

Overnight Payment Option

Signatures