ATTACHMENT A START-UP REQUEST FORM INSTRUCTIONS

ATTACHMENT A
START-UP REQUEST FORM
INSTRUCTIONS FOR COMPLETING THE “START-UP REQUEST FORM” TO RECEIVE FUNDS AS A
RESIDENTIAL HABILITATION PROVIDER AS SPECIFIED UNDER § 51.111 FOR START-UP OR LIFE SHARING
INITIATIVE FUNDS
This request form will only contain the request for funds for one waiver participant. However, if a waiver
participant qualifies for multiple initiatives (i.e. Chapter 51 and Life Sharing) the requests may be completed on
the same form. If a provider is requesting start-up funds for other individuals within the same residential
habilitation service location or other service locations if specified in the initiative criteria, then a separate form
must be completed for each waiver participant. All information is mandatory to process the request.
Step 1:
The person completing the request form shall enter the provider’s name on the first blank space
provided on the form.
Step 2:
By completing the Request Form, the provider is affirming that funds will be used in accordance
with the requirements set forth under § 51.111 for start-up and Life Sharing Initiative
requirements.
Step 3:
Please place an “X” in the checkbox (es) next to the reason(s) why you are requesting funds from
ODP. Please note that a provider can qualify for funds under each category, start-up under
§51.111 or Life Sharing Initiative separately and distinct from each other, if they meet the
requirements for each initiative. However, the maximum combined amount is $5,000. If you
place an “X” in the box next to the word “Other”, then please describe the reason for the funds.
The explanation can be entered in the space provided below the word “Other”. If you did not
select “Other” but you have comments that could impact an ODP determination, please enter
those comments in the space below “Other”. The “Other” section should be used to briefly
describe how the funds received from the Life Sharing Initiative are expected to offset lifesharing
development costs and/or expand Life Sharing activities.
Step 4:
Please enter the contact information for the person who would answer any question ODP may
have while reviewing this request. Please include the contact person’s name, phone number and
email address.
Step 5:
Please enter the provider’s 9-digit MPI*number that matches the cost report that was submitted
and as it appears in HCSIS. If different, list the 9-digit MPI that will support the waiver participant,
4-digit SLC, Recipient Identification Number (MCI), and the dollar amount requested (not to
exceed $5,000 per person).
Step 6:
The remainder of the form will be completed by ODP after a determination has been made as to
the availability of funds and whether the request meets criteria for approval.
Please e-mail this form to the ODP Regional Program Manager associated with the AE who will
authorize services for the waiver participant identified. Enter “Start-Up Request Form” in the email subject line.
Office of Developmental Programs
ATTACHMENT A
START-UP REQUEST FORM
(Enter Provider Name) is requesting approval for funds for a waiver participant new to the
provider. By making this request, the provider above is affirming that funds will be spend in accordance with start-up under
§51.111 and/or Life Sharing Initiative requirements. Please check the box (es) that apply to your particular request. I am
applying for:
Chapter 51.111 Start-Up Requests
Start-up costs relating to one-time activities related to opening a new facility (including but not limited to furniture)
Start-up costs to introducing a new product or service
Start-up costs to initiating a new process in an existing facility
Start-up costs to activities related to organizing a new entity
Life Sharing Initiative Requests
Start up for Life Sharing Initiative
Other: please describe the reason for requesting funds in the space below, if not identified above.
Explanation for selecting “Other”:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Contact Person’s Name
Contact Person’s Phone Number
Contact Person’s e-mail address
*COST REPORT MPI: 9-digit
SERVICING MPI: 9-digit
4-digit Service
Location Code (SLC)
Recipient Identification Number
(RID) also known as MCI
Amount Requested/Units
(not to exceed $5,000 per
person **
$
ODP REGIONAL OFFICE DECISION
APPROVED
DISAPPROVED
ODP FUNDING AVAILABILITY
AVAILABLE
NOT AVAILABLE
AUTHORIZATION PERIOD:
* If a provider has multiple MPI numbers then enter the MPI number under which the cost report
was submitted
** Documentation, including receipts, must be made available upon request
** The claim submitted can only be for the maximum amount spent which may not be the
maximum amount approved in this request
Office of Developmental Programs