Department of Health | State of Louisiana



Department of Health and HospitalsOffice for Citizens with Developmental DisabilitiesTRANSITIONAL EXPENSES PLANNING AND APPROVAL (TEPA) REQUEST FORMInstructions: 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: FORMTEXT SSN: FORMTEXT ?????WAIVER POPULATION: FORMCHECKBOX NOW FORMCHECKBOX ROWOCDD REGIONAL OFFICE: FORMTEXT ?????CURRENT ICF/DD FACILITY: FORMTEXT ????? PROJECTED MOVE DATE: FORMTEXT ????? ACTUAL MOVE DATE: FORMTEXT ????? PRE-142 APPROVAL DATE: FORMTEXT ????? FINAL APPROVED TEPA DATE: FORMTEXT ????? TOTAL ESTIMATED TEPA COST: FORMTEXT ????? TOTAL ACTUAL TEPA COST: FORMTEXT ????? INITIAL PLAN OF CARE END DATE: FORMTEXT ????? ITEMIZED EXPENSE INFORMATIONAREAITEMDESIGNATED PURCHASER’S INITIALSNUMBER OF ITEMS REQUESTEDESTIMATED COST RANGEESTIMATED COSTACTUAL COSTBASED ON RECEIPTLIVING ROOMSOFA FORMTEXT ????? FORMTEXT ?????$250-$440 FORMTEXT ????? FORMTEXT ?????LOVE SEAT FORMTEXT ????? FORMTEXT ?????$150-$300 FORMTEXT ????? FORMTEXT ?????CHAIR FORMTEXT ????? FORMTEXT ?????$75-$150 FORMTEXT ????? FORMTEXT ?????COFFEE TABLE FORMTEXT ????? FORMTEXT ?????$50-$70 FORMTEXT ????? FORMTEXT ?????END TABLE FORMTEXT ????? FORMTEXT ?????$50-80 FORMTEXT ????? FORMTEXT ?????WALL HANGINGS FORMTEXT ????? FORMTEXT ?????$10-$45 FORMTEXT ????? FORMTEXT ?????RECLINER FORMTEXT ????? FORMTEXT ?????$140-$210 FORMTEXT ????? FORMTEXT ?????DINING ROOMDINING TABLE/CHAIRS FORMTEXT ????? FORMTEXT ?????$140-$210 FORMTEXT ????? FORMTEXT ?????KITCHENDISHES/PLATES FORMTEXT ????? FORMTEXT ?????$15-$30 FORMTEXT ????? FORMTEXT ?????GLASSWARE FORMTEXT ????? FORMTEXT ?????$5-$15 FORMTEXT ????? FORMTEXT ?????CUTLERY/FLATWARE FORMTEXT ????? FORMTEXT ?????$15-$30 FORMTEXT ????? FORMTEXT ?????MICROWAVE FORMTEXT ????? FORMTEXT ?????$30-$70 FORMTEXT ????? FORMTEXT ?????COFFEE MAKER FORMTEXT ????? FORMTEXT ?????$10-$20 FORMTEXT ????? FORMTEXT ?????POTS/PANS FORMTEXT ????? FORMTEXT ?????$35-$70 FORMTEXT ????? FORMTEXT ?????MISCELLANEOUS (DRAIN BOARD, DISH CLOTHS/TOWELS,POT HOLDERS,STORAGE CONTAINERS,BROOM,MOP/BUCKET) FORMTEXT ????? FORMTEXT ?????$50-$300 FORMTEXT ????? FORMTEXT ?????MISCELLANEOUS (IRON, SMALL KITCHEN APPLIANCES) FORMTEXT ????? FORMTEXT ?????$25-$75 FORMTEXT ????? FORMTEXT ?????BATHROOMMISCELLANEOUS(TOWELS, HAMPER,SHOWER CURTAIN,PERSONAL CARE ITEMS,BATH MATS) FORMTEXT ????? FORMTEXT ?????$50-$150 FORMTEXT ????? FORMTEXT ?????AREAITEMDESIGNATED PURCHASER’S INITIALSNUMBER OF ITEMS REQUESTEDESTIMATED COST RANGEESTIMATED COSTACTUAL COST BASED ON RECEIPTBEDROOMBEDROOM SET INCLUDING MATTRESS/BOXSPRINGS FORMTEXT ????? FORMTEXT ?????$250-$500 FORMTEXT ????? FORMTEXT ????? NIGHT STAND FORMTEXT ????? FORMTEXT ?????$75-$100 FORMTEXT ????? FORMTEXT ?????MISCELLANEOUS (COMFORTER, SHEETS, PILLOWS, LAMPS, CURTAINS) FORMTEXT ????? FORMTEXT ?????$100-$300 FORMTEXT ????? FORMTEXT ?????MOVING EXPENSESMOVING COMPANY FORMTEXT ????? FORMTEXT ?????$100-$200 FORMTEXT ????? FORMTEXT ?????HEALTH AND SAFETYONE-TIME CLEANING FEE FORMTEXT ????? FORMTEXT ?????$25-$100 FORMTEXT ????? FORMTEXT ?????PEST ERADICATION FORMTEXT ????? FORMTEXT ?????$50-$150 FORMTEXT ????? FORMTEXT ?????ALLERGEN CONTROL FORMTEXT ????? FORMTEXT ?????$25-$30 FORMTEXT ????? FORMTEXT ?????FIRE EXTINGUISHER FORMTEXT ????? FORMTEXT ?????$30-$40 FORMTEXT ????? FORMTEXT ?????SMOKE DETECTOR FORMTEXT ????? FORMTEXT ?????$10-$20 FORMTEXT ????? FORMTEXT ?????FIRST AID KIT / SUPPLIES FORMTEXT ????? FORMTEXT ?????$15-$40 FORMTEXT ????? FORMTEXT ?????NON-REFUNDABLE SETUP FEESTELEPHONE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ELECTRICITY FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HEATING BY GAS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTALS: FORMTEXT FORMTEXT ?????SUPPORT COORDINATION INFORMATIONSUPPORT COORDINATION AGENCY: FORMTEXT ????? TELEPHONE NUMBER(S): FORMTEXT ?????ADDRESS: FORMTEXT ????? E-MAIL ADDRESS: FORMTEXT ?????SUPPORT COORDINATOR’S NAME: FORMTEXT ?????SUPPORT COORDINATOR’S SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ????? DESIGNATED PURCHASER INFORMATIONDESIGNATED PURCHASER’S NAME: FORMTEXT ?????AGENCY: FORMTEXT ?????ADDRESS: FORMTEXT ?????E-MAIL ADDRESS: FORMTEXT ?????DESIGNATED PURCHASER’S SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????DESIGNATED PURCHASER’S NAME: FORMTEXT ?????AGENCY: FORMTEXT ?????ADDRESS: FORMTEXT ?????TELEPHONE NUMBER: FORMTEXT ?????DESIGNATED PURCHASER’S SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????OCDD PRE-APPROVED SERVICE AUTHORIZATION AMOUNT: $ FORMTEXT ?????OCDD REGIONAL OFFICE SIGNATURE: FORMTEXT ????? ................
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