MSFS of UT Request for FTS Payment- New Choices

MSFS of UT Request for FTS Payment- New Choices

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
Case Management Agency:
Date of Request:

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

Confirmation Emailexample@example.com
Approval by the New Choices Waiver Program Office is required for all FTS requests via the care plan process. Has this request, including reimbursement above the MAR if applicable, been approved on the care plan?
Date of formal care plan approval

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this client a new enrollment/re-enrollment
If yes, provide the (re)enrollment date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDo not send until client has actually moved onto the program
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 / Province

Postal / Zip Code
Assistive Technology Devices

HCPCS Code T2028
Do you have an entry for this section? (HCPCS Code T2028)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2028 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2028 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Environmental Accessibility Adaptations - Home Modifications

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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Environmental Accessibility Adaptations - Vehicle Modifications

HCPCS Code T2039
Do you have an entry for this section? (HCPCS Code T2039)
Service Code Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2039 Start Date on Care Plan
Service Code End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearT2039 End Date on Care Plan
Number of Units
Service/Item(s) Cost
Service Total Cost
Description
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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Specialized Medical Equipment

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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
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
Service/Item(s) Cost
Service Total Cost
Description
File Upload

Cancelof
Non-medical Transportation - Public Transit Pass

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

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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.
CMA FTS Coordinator Name (Print)

First NameLast Name
CMA FTS Coordinator Signature
CMA FTS Coordinator Signature Date

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

MSFS of UT Request for FTS Payment- New Choices

Assistive Technology Devices

Environmental Accessibility Adaptations - Home Modifications

Environmental Accessibility Adaptations - Vehicle Modifications

Community Living Services

Specialized Medical Equipment

Chore Services

Non-medical Transportation - Public Transit Pass