REQUEST FOR SPECIAL BEQUEST COMMISSION FUNDING (FOR THOSE WHO

 STUDENT ID DUPLICATE CREDENTIAL REQUEST FEE CHARGED
(JAWAPAN PADA SLAID) 1 A MANAGER REQUEST HIS
048B DATE OF BIRTHADDRESS CHANGE REQUEST FORM

2 REQUEST FOR NCG FUNDING FOR RITUXIMAB
2 REQUEST FOR URGENT CITIZENSHIP CEREMONY –
APPLICATION TO THE REGISTRAR TO REQUEST THE PRODUCTION

Date Submitted: ?????

REQUEST FOR SPECIAL BEQUEST COMMISSION FUNDING

(For Those who are on the Special Health Care Needs Program)

Date Submitted: Date Reviewed:      

Child’s name:

DOB:

Recommended by:

Title/Specialty:

Diagnosis:


Is child seen in SHS Specialty clinic? Yes No If yes, name of clinic(s)



Has this child been a recipient of Special Bequest funding in the past? Yes No



If yes, provide summary or attach a funding history:



Item/service requested:


Total cost: $ Amount requested:


Briefly explain reason for request:



Is item available from Kansas Equipment Exchange (KEE or like program)? Yes No


Submitted to Medicaid? Yes No Submitted to Insurance? Yes No


Does the child receive SSI? Yes No


List funding resources that have been contacted and response (including family contribution):


Attach a description of health problems, including how the item or service will enhance the child’s ability, or reduce the risk of injury to caregivers or child (information should be submitted from a licensed provider, not from a vendor).




Family composition, income and brief social history





Special Health Service contact person: Office: SHS, Topeka

Special Bequest determination:

Approved: Amount       Denied: Comments:


CHAIRMAN PHIL MENDELSON AT THE REQUEST OF THE
FREEDOM OF INFORMATION ACT REQUEST PLEASE REVIEW
FRESNO COUNTY EMPLOYEES’ RETIREMENT ASSOCIATION REQUEST FOR PROPOSAL


Tags: bequest commission, special bequest, those, special, request, commission, funding, bequest