Department of Health and Hospitals Office for Citizens with Developmental Disabilities TRANSITIONAL EXPENSES PLANNING AND APPROVAL (TEPA) REQUEST FORM Instructions: Each item purchased must be indicated in the appropriate area with the actual cost of the item, based on the receipt, indicated in the Cost Based on Receipt” column. All sections of this form must be filled out completely and contain all “Actual appropriate signatures in order to process the request. PARTICIPANT’S SSN: NAME: WAIVER NOW ROW OCDD REGIONAL OFFICE: POPULATION: CURRENT ICF/DD FACILITY: PROJECTED MOVE DATE: ACTUAL MOVE DATE: PRE-142 APPROVAL DATE: FINAL APPROVED TEPA DATE: TOTAL ESTIMATED TEPA COST: ACTUAL TEPA COST: INITIAL PLAN OF CARE END DATE: ITEMIZED EXPENSE INFORMATION AREA ITEM ACTUAL DESIGNATED NUMBER OF ITEMS COST COST COST INITIALS RANGE ON RECEIPT SOFA $250-$440 LOVE SEAT $150-$300 CHAIR $75-$150 LIVING COFFEE TABLE $50-$70 ROOM END TABLE $50-80 WALL HANGINGS $10-$45 RECLINER $140-$210 DINING DINING $140-$210 ROOM KITCHEN DISHES/PLATES $15-$30 GLASSWARE $5-$15 $15-$30 MICROWAVE $30-$70 COFFEE MAKER $10-$20 POTS/PANS $35-$70 MISCELLANEOUS (DRAIN BOARD, DISH CLOTHS/TOWELS, $50-$300 POT HOLDERS, STORAGE CONTAINERS, MOP/BUCKET) MISCELLANEOUS $25-$75 (IRON, SMALL KITCHEN APPLIANCES)
Department of Health and Hospitals Office for Citizens with Developmental Disabilities TRANSITIONAL EXPENSES PLANNING AND APPROVAL (TEPA) REQUEST FORM Instructions: Each item purchased must be indicated in the appropriate area with the actual cost of the item, based on the receipt, indicated in the “Actual Cost Based on Receipt” column. All sections of this form must be filled out completely and contain all appropriate signatures in order to process the request. PARTICIPANT’S NAME: SSN: WAIVER POPULATION: NOW ROW OCDD REGIONAL OFFICE: CURRENT ICF/DD FACILITY: PROJECTED MOVE DATE: ACTUAL MOVE DATE: PRE-142 APPROVAL DATE: FINAL APPROVED TEPA DATE: TOTAL ESTIMATED TEPA COST: ACTUAL TEPA COST: INITIAL PLAN OF CARE END DATE: ITEMIZED EXPENSE INFORMATION AREA ITEM DESIGNATED INITIALS NUMBER OF ITEMS COST RANGE COST ACTUAL COST ON RECEIPT LIVING ROOM SOFA $250-$440 LOVE SEAT $150-$300 CHAIR $75-$150 COFFEE TABLE $50-$70 END TABLE $50-80 WALL HANGINGS $10-$45 RECLINER $140-$210 DINING ROOM DINING $140-$210 KITCHEN DISHES/PLATES $15-$30 GLASSWARE $5-$15 $15-$30 MICROWAVE $30-$70 COFFEE MAKER $10-$20 POTS/PANS $35-$70 MISCELLANEOUS (DRAIN BOARD, DISH CLOTHS/TOWELS, POT HOLDERS, STORAGE CONTAINERS, MOP/BUCKET) $50-$300 MISCELLANEOUS (IRON, SMALL KITCHEN APPLIANCES) $25-$75
OCDDWSS-R-09-008_TEPA_Request_Form_11-18-09.docx