Transitional Moving Services Referral Form

Provider Name	UMPI Number	Description	Procedure Code
Oak Tree Support Services	A123637100	Household Items	T2038-U2 ($300)
Oak Tree Support Services	A123637100	Furniture	T2038-U1 ($1,000)
Oak Tree Support Services	A123637100	Moving Services, Delivery, Damage Deposit, Mileage, and Labor	T2038 ($1,700 or Package B = $3,000)

Important Note: Above are the Service Agreement numbers needed to submit your client's Service Agreement through your client's CADI waiver. Please note, we are now requiring the Service Agreement be submitted and approved before your client can receive services. We can provide a letters of guarantees and book the movers, but we are unable to send any physical items for the client until the Service Agreement has been received as approved.

All moves must have a referral form before they can be finalized. Any referral received less than 10 business days before the planned move is subject to availability and may be declined.

"*" indicates required fields

Client Information:

Client Name*

First Last

Date of Birth*

Diagnosis

Phone Number*

Do you have an Oak Tree Support Services Housing Coordinator*

Yes

Emergency Contact Name*

Emergency Contact Phone Number*

Case Manager Information:

First Name*

First

Last Name*

Last

Organization*

Email*

Phone*

Moving Information:

Date of Move:

Current location:*

(where they are moving from)

Street Address Address Line 2 City State ZIP Code

New location:

(where they are moving to)

Street Address Address Line 2 City State ZIP Code

Is there a secondary location for items needing to be moved?*

Yes

Are there any fees needing to be paid through Transitional Services? Where should the check be made out to and sent?*

Select a Package:*

Package A: Includes: moving supply package, movers, moving truck, up to $250 in deposits, if moving budget allows potentially $1000 in furniture and $300 in household goods from TS catalog
Household: $300 Furniture: $1000 Move: $1700

Package B: Includes: moving supply package, movers, moving truck, and up to $1000 in deposits. This does not come with any furniture or household goods. This package can also be used for clients who are moving 1 hour or more outside of the cities. This will allow for a long distance move.
Household: $0 Furniture: $0 Move: $3,000

Package C “the drop off package”: This package is for individuals that only need new furniture and household goods to be transported to the new location. Includes: staff, supplies needed, transportation of items, up to $500 in deposits, $1000 in furniture and $300 in household goods from the TS catalog
Household: $300 Furniture: $1000 Move: $1700

Please include any additional documentation required

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 300 MB, Max. files: 3.

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