Get Emergency Fund Request Form

The Emergency Fund Request Form is designed to facilitate requests for unanticipated emergency funding when certain circumstances arise. This guide provides a clear and comprehensive overview of how to fill out the form online, ensuring users can navigate it with confidence and ease.

Follow the steps to complete the Emergency Fund Request Form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the first section, provide the name of the County Program or Administrative Entity that has determined the emergency situation. Keep in mind to be specific about the details regarding the circumstances.
3. Fill out the field marked 'individual’s name' with the full name of the person requesting funding. This ensures the request is accurately associated with the appropriate individual.
4. Complete the 'procedure code' field as required, using the codes relevant to the emergency situation being addressed.
5. Input the 'date of request' to indicate when the application is being made. This helps in tracking and recording the timing of the request process.
6. Enter the 'MCI #' which is used for identification. Ensure that this information is correct to avoid processing delays.
7. Fill in the 'service location code' to specify where the services will be rendered.
8. Detail the 'units' for each requested service. This assesses the amount of service being applied for and must match the procedure codes listed.
9. Provide the 'provider name (MPI)' to identify the service provider associated with the funding request.
10. Include information about the County Program or Administrative Entity representative handling the request. This establishes a point of contact for follow-up.
11. Review the section regarding ODP Regional Office decision. Indicate if the request has been 'approved' or 'disapproved' based on prior evaluations.
12. Specify the 'authorization period' for which the funding is requested. This typically covers a timeframe of up to 15 days for service provision.
13. Finally, review all entries for accuracy. Save any changes made to the form. You can download, print, or share the completed form as needed.

Ensure your Emergency Fund Request Form is filled out accurately and completely online to expedite the approval process.