mdhhs-5822, pre-approval request for foster parent mileage reimbursement for visitation travel over 250 miles round trip

Michigan Department of Health and Human Services

(Revised 02-22)

section 1 – instructions

Round trip travel is defined as the distance from the foster parent’s home to the location of parenting time/sibling visitation and back. All pre-approvals must be renewed every quarter (90 days). Complete one pre-approval request form for each child/sibling group being transported by the foster parent (attach extra pages if necessary). Submit the pre-approval request by email to the Federal Compliance Division at MDHHS-federalcompliancedivision@michigan.gov at least 24 hours prior to the anticipated date of travel, along with a MapQuest or Google Maps of the round trip route.

section 2

Child's Name 1	Date of Birth 1	MiSACWIS Person ID

Legal Status	Fund Source

Child's Name 2	Date of Birth 2	MiSACWIS Person ID

Legal Status	Fund Source

Foster Parent Name(s)	Foster Parent MiSACWIS Provider ID

Foster Parent Street Address	City	State	Zip Code

Type of Visitation Sibling Visitation Parenting Time Visitation

Visit Street Address	City	State	Zip Code

Number of Visits

Week	Month	One-time visit	Visit Begin Date

Request for Quarter(s) January - March April – June July – September October - December

Comments

Primary Worker Signature (MDHHS or PAFC)	Date

section 3 – federal compliance division approval

Number of round trips	Mileage units	Maximum mileage units	Service Authorization maximum amount $

Federal Compliance Division Supervisor Approval	Date

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.