MSFS of UT Request for FTS Payment- Aging Waiver

MSFS of UT Request for FTS Payment- Aging Waiver

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Participant's First and Last Name:

First NameLast Name
Care Plan Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearStart Date of Care Plan
Care Plan End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnd Date of Care Plan
Participant's Address

Street Address

Street Address Line 2

CityState

Zip Code
Participant's Medicaid ID:
Participant's Gender (For Billing)
Participant's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Area Agency on Aging (AAA):
Date of Request:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email

Confirmation Emailexample@example.com
Has the AAA Approved the below service(s) or item(s) on the care plan?
Date of Care Plan Approval

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does this Request Require Division of Aging & Adult Services (DAAS) approval?
If yes, provide the approval date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DAAS approval received from:
Request Type?
Make Check Payable To (Vendor):
Enter website for online orders
Vendor FEIN or SSN:
File Upload - Vendor W9

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Vendor Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Chore Services

HCPCS Code S5120
Do you have an entry for this section? (HCPCS Code S5120)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5120 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5120 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS approval is required for services costing more than $1000.00
File Upload

Cancelof
Environmental Accessibility Adaptations

HCPCS Code S5165
Do you have an entry for this section? (HCPCS Code S5165)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5165 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5165 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS approval is required for services costing more than $2000.00
File Upload

Cancelof
Supplemental Meals

HCPCS Code S5170
Do you have an entry for this section? (HCPCS Code S5170)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5170 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearS5170 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Specialized Medical Equipment/Supplies/Assistive Technology

HCPCS Code T2029
Do you have an entry for this section? (HCPCS Code T2029)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2029 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2029 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS Approval for items over $1000.00
File Upload

Cancelof
Community Living Services

HCPCS Code T2038
Do you have an entry for this section? (HCPCS Code T2038)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2038 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2038 End Date on Care Plan
Number of Units
Services/Item(s) Cost
Service Total Cost
Description
*DAAS Approval for items over $1000.00
File Upload

Cancelof
Non-Medical Transportation

HCPCS Code T2003
Do you have an entry for this section? (HCPCS Code T2003)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2003 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2003 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Non-Emergency Transportation

HCPCS Code T2004
Do you have an entry for this section? (HCPCS Code T2004)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2004 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2004 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Total Check Amount
By signing this form, I attest that services have been delivered and received consistent with the participant’s approved care plan and that this payment request is in accordance with the AW Program regulations. I understand that payment of this claim will be from Federal and State funds, and that false claims, statements or documents or concealment of a material fact may be prosecuted under applicable Federal or State laws. Any misuse of funds may result in being fined or penalized, including but not limited to repayment of a claim.
AAA FTS Coordinator Name (Print)

First NameLast Name
AAA FTS Coordinator Signature
AAA FTS Coordinator Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

MSFS of UT Request for FTS Payment- Aging Waiver

Chore Services

Environmental Accessibility Adaptations

Supplemental Meals

Specialized Medical Equipment/Supplies/Assistive Technology

Community Living Services

Non-Medical Transportation

Non-Emergency Transportation