Get Fee Reduction / Waiver For Preexisting Services ...

This guide provides clear and detailed instructions for filling out the FEE REDUCTION / WAIVER FOR PREEXISTING SERVICES form online. By following these steps, users can ensure they provide all necessary information to facilitate a smooth approval process.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Enter the name of the person receiving services in the corresponding field. This identifies who the fee reduction or waiver request is for.
3. Fill in the service provider's name and their TABS ID number. Ensure accuracy as this information is critical for processing the request.
4. Provide the service provider's tax ID number and the TABS agency code. This information is necessary for tax and identification purposes.
5. Input the service provider's contact information, including their phone number and address, to facilitate communication.
6. Indicate the type of services being provided by selecting from the available options in the form.
7. Include the OPWDD TABS program code(s) which correspond to the services outlined in the previous step.
8. Select the type of authorization being requested, either Fee Reduction or Fee Waiver. Mark the appropriate box.
9. Provide a detailed reason for requesting a fee reduction or waiver, explaining the circumstances necessitating the request.
10. Enter the date of birth of the person receiving services.
11. Document the maximum amount to be charged to the individual each month based on OPWDD guidelines provided in the form.
12. Indicate the Medicaid status of the individual by selecting Yes, No, or Pending. If ineligible, provide a reason.
13. If the Medicaid application has been denied, check the boxes to confirm that attached photocopies of the required documents are included.
14. If applicable, provide the yearly taxable income of the parents if the individual is under 21 and living with them.
15. If a Medicaid application has not been filed, provide a detailed explanation and attach any relevant documentation.
16. Complete the HCBS waiver status section by selecting the applicable option and providing additional details if required.
17. In the attestation section, confirm the accuracy of the information provided and include the name, title, and signature of the service provider.
18. Review the entire form to ensure all sections are completed accurately before proceeding to submit.
19. After completing the form, users can save changes, download, print, or share the form as needed.

Fill out the form online today to start the process of obtaining a fee reduction or waiver.