BOTS Self-Direct Form

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authorization to direct bill my OPWDD FI

Thank you for your interest in a Bring On The Spectrum membership. We will bill your fiduciary each month for your membership . The membership fee auto renews each month until you notify us to pause or cancel in writing.

Once this form is completed, we will contact you, your broker and your FI in a group email so they can confirm your self-direction budget has the necessary budget line item and funds. Once all is aligned, BOTS will send a welcome email with details on how to use your membership and make reservations for open play.

Email questions to BringOnTheSpectrum@gmail.com or call/text 518-641-1971

Club Member's First Name *

Club Member's Last Name *

email address *

Care Manager Email Address (Care Design, Life Plan, Tri County Care) *

Broker Email Address *

Fiscal Intermediary Agency Name (ex. AIM, Wildwood, ARC, etc). *

Fiscal Intermediary Contact Name *

Fiscal Intermediary Contact Phone Number *

Fiscal Intermediary Contact Email Address *

what county do you reside? *

Authorized signer (name) *

Authorized signer email address *

I understand that my initials below as parent/guardian/approved agent is legally binding as my printed signature *

Submit

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