Special Service Fee and Payment Extension Request Instructions
This form contains 38 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency Name | ||
| Agency Name | Text |
Please provide the full name of the agency.
|
| Caseworker Information | ||
| Caseworker Name | Text |
Please provide the full name of the caseworker.
|
| Caseworker ID | Text |
Please provide the identification number for the caseworker.
|
| Client Information | ||
| Client Name | Text |
Please provide the full name of the client.
|
| Client ID | Text |
Please provide the identification number for the client.
|
| Form Type | ||
| Special Service Fee | Checkbox |
Check this box if this form is being used to request a special service fee.
|
| Payment Extension | Checkbox |
Check this box if this form is being used to request a payment extension.
|
| General | ||
| Text32 | Text | |
| Text33 | Text | |
| Text34 | Text | |
| Text35 | Text | |
| Text36 | Text | |
| Text37 | Text | |
| Text38 | Text | |
| Text39 | Text | |
| Text40 | Text | |
| Text41 | Text | |
| Text42 | Text | |
| Text43 | Text | |
| Text44 | Text | |
| Text45 | Text | |
| Text46 | Text | |
| Narrative | ||
| Narrative | Text |
Please provide a detailed narrative regarding the special service fee or payment extension request.
|
| Placement Date | ||
| Placement Date Month | Date |
Provide the month for the placement date.
|
| Placement Date Day | Date |
Provide the day for the placement date.
|
| Placement Date Year | Date |
Provide the year for the placement date.
|
| Provider Information | ||
| Provider Name | Text |
Enter the full name of the service provider.
|
| Provider ID | Text |
Enter the identification number assigned to the provider.
|
| Regional Administrator Name | ||
| Regional Administrator Name | Text |
Please enter the full name of the regional administrator.
|
| SSF Details | ||
| SSF Amount | Number |
Enter the total amount of the Special Service Fee. Fill only if 'Special Service Fee' is 'Yes'.
Depends on:
Special Service Fee
|
| Reason for SSF | Text |
Provide a detailed reason for the Special Service Fee. Fill only if 'Special Service Fee' is 'Yes'.
Depends on:
Special Service Fee
|
| Start Date | ||
| Start Date Month | Date |
Please enter the month for the start date.
|
| Start Date Day | Date |
Please enter the day for the start date.
|
| Start Date Year | Date |
Please enter the year for the start date.
|
| Stop Date | ||
| Stop Date Month | Text |
Provide the month of the stop date.
|
| Stop Date Day | Text |
Provide the day of the stop date.
|
| Stop Date Year | Text |
Provide the year of the stop date.
|
| Supervisor Name | ||
| Supervisor Name | Text |
Please enter the full name of the supervisor.
|