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Itasca County Authorizations:________________ Date:________
Date:____________to_______________ 99 _____
1. Client has serious and persistent mental illness and has a case manager.
2. No other funding source is available, i.e. Salvation Army, Kootasca, foodshelf, or sharing fund.
3. Prior to request, check with rep payee to determine if client has personal funds available.
4. Funding supports client to prevent/reduce hospitalization, enhance stability in community and increase independence.
5. Whenever possible, clients will be encouraged to plan ahead to pay for their needs. When emergency need arises for shelter, transportation or medical purposes, the client discretionary fund may be considered. Phones are not necessities unless client has a Pal unit.
6. Requests will be made in writing to Craig Pierce, ICHHS MH Coordinator (BLL and SP backup) (FAX 327-5535) who will authorize/deny and inform case manager/representative and accounting.
7. Flex requests are processed weekly, checks are written on Thursday and mailed on Friday. ALL REQUESTS NEED TO BE RECEIVED AT ICHHS BY 4:30 P.M. ON WEDNESDAY TO BE PROCESSED THURSDAY. Dee.Gielen@co.itasca.mn.us
8. LIMIT OF $500.00 PER CLIENT PER CALENDAR YEAR. A PLAN TO PAY BACK THE FLEX FUND MUST BE ESTABLISHED WITH THE CLIENT PRIOR TO THE REQUEST BEING MADE.
9. This application form only must be used and must be filled out completely and accurately. Incomplete forms will not be processed. One request is allowed per sheet.
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