Form 287I HCW Forced Payment Form

Seniors and People with Disabilities /

OPIForced Payment Request

Branch #
Date Completed (MM/DD/YY) / //
Submitted by
Phone #
Worker email address
Client Name
Client Prime #
Provider Name
Provider #

Exceptional Rate Approved by SPD Central Office

(If above the SPD/AAA local office approval amount)

USE HINQ SCREENS TO COMPLETE - NOTE: Some vouchers have several procedures on them. You must enter each procedure code, but you only need to enter voucher # and date once.

Pay Existing Voucher

Voucher # / Authorized
Begin Date
(MM/DD/YY) / Authorized
End Date
(MM/DD/YY) / Procedure Code and Description
(For each voucher #, choose all that apply) / Units Paid (hours)
// / // / OP334 ADL Full AssistOP334 ADL Subst AssistOP334 ADL Minimal AsstOP334 Self ManagementTU111 Hrly Paid LeaveOP333 Chore Full AsstOP333 Chore Subst AsstOP333 Chore Min AsstOP333 Chore Self MgmntOP336 Mileage/Pub Trans
// / // / OP334 ADL Full AssistOP334 ADL Subst AssistOP334 ADL Minimal AsstOP334 Self ManagementTU111 Hrly Paid LeaveOP333 Chore Full AsstOP333 Chore Subst AsstOP333 Chore Min AsstOP333 Chore Self MgmntOP336 Mileage/Pub Trans
// / // / OP334 ADL Full AssistOP334 ADL Subst AssistOP334 ADL Minimal AsstOP334 Self ManagementTU111 Hrly Paid LeaveOP333 Chore Full AsstOP333 Chore Subst AsstOP333 Chore Min AsstOP333 Chore Self MgmntOP336 Mileage/Pub Trans

Instructions to Add or Delete a Row:

Use floating SCREENS TOOLBAR. If you do not have the blue and grey floating toolbar, click “VIEW,” “TOOLBARS” & select “SCREENS TOOLBAR.”

Provider Signature Date: / Enter date here
Client Signature Date: / Enter date here

Create Next Pay Period Voucher

Authorized
Begin Date
(MM/DD/YY) / Authorized
End Date
(MM/DD/YY) / Procedure Code and Description
(For each voucher #, choose all that apply) / Units Paid (hours)
// / // / OP334 ADL Full AssistOP334 ADL Subst AssistOP334 ADL Minimal AsstOP334 Self ManagementTU111 Hrly Paid LeaveOP333 Chore Full AsstOP333 Chore Subst AsstOP333 Chore Min AsstOP333 Chore Self MgmntOP336 Mileage/Pub Trans
// / // / OP334 ADL Full AssistOP334 ADL Subst AssistOP334 ADL Minimal AsstOP334 Self ManagementTU111 Hrly Paid LeaveOP333 Chore Full AsstOP333 Chore Subst AsstOP333 Chore Min AsstOP333 Chore Self MgmntOP336 Mileage/Pub Trans

Reason for Forced Payment:

Page 1 of 2 SDS 0287i (4/07)

Click here forsubmitting instructionsSubmitting Instructions

Option #1:

Prior to clicking the Submit Requestbutton on the form, write down or copy email address listed below

Click the Submit Request button

Completed forms will automatically attach to the email

Fill in the To section of the email with the email address below

Send email

Option #2:(Use this option if unable to use option #1)

Save form

Open Groupwise or other email system

Attach form to email

Send to address below

Choose Email Address to Use

Groupwise Users / Users Outside of Groupwise
ProviderAdjustment, SPD /

Click heretoreturn to page 1

Page 1 of 2 SDS 0287i (4/07)