Public Guardianship and ConservatorSHIP RequEst for Reimbursement
Michigan Department of Health and Human Services
In accordance with PA 207 of 2018, Section 950, the department shall allocate not more than $1,500,000.00 to reimburse counties for 50% of the cost to reimburse court-appointed public guardians and conservators for recipients who also receive Community Mental Health Services Program (CMHSP) services. The maximum monthly reimbursement is $41.50. When the allocated funding has been exhausted, requests for reimbursement will no longer be considered.
1. County/Vendor Name	2. Name and Phone Number of County Contact
3. Address of County Office
4. Name of Guardian/Conservator providing services to the individual for which reimbursement is being sought
5. Name of individual receiving guardianship/ conservatorship services (If more than one individual use table on page 2)	6. Medicaid ID(s)
7. County of residence for individual
8. Name of CMHSP or contracted CMHSP provider the individual is receiving services from
9. Attach proof that each individual received at least one CMHSP service during the month(s) in which reimbursement is being sought. (It can be attestation from the guardian/conservator indicating the date and type of service received. Attestations will be audited to validate service encounters.) If an individual does not receive CMHSP services during the month(s) for which reimbursement is requested, the request will be denied.
10. Attach invoice(s) for proof of county payment for each individual for which reimbursement is being sought.
11. Amount requested	12. Month(s) covered
13. SIGMA Vendor ID
14. Requester Signature	15. Date
16. Submit completed form with attachment(s) to: MDHHS-BHDDA-Contracts-MGMT@michigan.gov
MDHHS OFFICE USE ONLY
Accounting Template	Unit Code
Approver Signature	Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

LIST ADDITIONAL INDIVIDUALS (This page can be duplicated if needed)
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from
Name of individual receiving guardianship/ conservatorship services	Medicaid ID(s)
County of residence for individual	Name of guardian/conservator
Name of CMHSP/PIHP provider the individual is receiving services from

instructions for completing the public guardianship and conservatorSHIP request for reimbursement
Box 1:	Indicate the name of the County or the Vendor name associated with the State of Michigan that is requesting reimbursement.
Box 2:	Provide the name and phone number of the person from the county that can be contacted if there are questions about the information submitted.
Box 3:	Provide the complete address of the county office.
Box 4:	Indicate the name of the guardian/conservator that has been charged with providing services to the individual for which reimbursement is being requested.
Box 5:	Provide the complete legal name of the individual receiving guardian/conservator services.
Box 6:	Provide the Medicaid identification number for the individua receiving services – this is used for auditing purposes by MDHHS.
Box 7:	Indicate the county of residence for the individual receiving guardian/conservator services.
Box 8:	Indicate the name of the CMHSP or the contracted CMHSP provider from which the individual is receiving behavioral health services.
Note:	If reimbursement is being sought for more than one person, please use the table of page 2 to provide the name of the individual, the Medicaid identification number, county of residence, name of guardian/conservator and the CMHSP or CMHSP contracted provider. This page may be duplicated if needed.
Box 9:	In order to qualify for reimbursement, MDHHS requires that each individual receive at least one service or support from the CMHSP or contracted CMHSP provider during the month in which reimbursement is being sought. MDHHS requires the proof of the service encounter be submitted with this form. This proof can be in the form of a receipt for services from the provider that includes the date and type of service provided. If a receipt is not available, an attestation from the guardian/conservator that includes the date and the type of service encounter that took place can be provided. If an attestation is provided, MDHHS will verify the service through the states data system as part of approving the request. If this request if for more than one month, there must be proof, or an attestation provided for each month.
Box 10:	In order to ensure that the county has paid the court-appointed public guardian/conservator for services in which this reimbursement is being requested, MDHHS requires that proof of the payment has been for the individual in question. This proof can be an invoice or another form of proof of payment and must contain the guardian/conservator name and the name of individual(s) identified on this form in Box 5 or the attached table.
Box 11:	Indicate the total amount of reimbursement being requested.
Box 12:	Indicate the month or months that the reimbursement covers.
Box 13:	Provide the SIGMA Vendor ID that you have been provided by the State of Michigan.
Box 14 and 15:	Provide the signature of the person requesting the reimbursement – electronic signatures are acceptable – and the date the form was completed.
Box 16:	Submit this form and all associated attachments to the email box that has been provided.