iBudget Waiver Enrollment Form 2025–2026

This form is used to indicate interest in enrolling in the iBudget Waiver. Please complete all applicable sections. If you have questions, contact the Agency for Persons with Disabilities at APDEnrollment@apdcares.org or call 1-833-312-5879.

Part A: Recipient Information

Please complete the following information about the Recipient.

iConnect ID:

First Name:

Last Name:

Middle Initial:

Address:

City:

State:

Zip:

Email Address:

Telephone #:

Medicaid ID # (if known):

Date Applied (if Medicaid ID is unknown):

If Medicaid ID is not available, this is the date the Recipient applied for Medicaid.

Part B: Household Information

Please complete the following information about the Recipient’s Parent (if a minor) or Legal Representative (if an adult)

Parent/Legal Representative First Name:

Parent/Legal Representative Last Name:

Parent/Legal Representative Address:

City:

State:

Zip:

Email:

Phone:

Do you have a sibling in a Pre-Enrollment Category?

Sibling's Pre-Enrollment Category:

Sibling’s Name:

Sibling’s Date of Birth:

Part C: Interest in iBudget Waiver Enrollment

Please select the YES or NO statement below for yourself or on behalf of the named individual:

YES, I accept the offer to enroll on the iBudget Florida Waiver.

NO, I do not want to enroll on the iBudget Florida Waiver. I understand that APD cannot guarantee a future enrollment opportunity date.

Part D: Certification and Signature

I certify that all information is true and correct to the best of my knowledge. My signature below verifies my interest statement above. I understand that signing this interest form does not guarantee enrollment into the program. Enrollment will be offered on a first-come, first-served basis to individuals who meet all components of eligibility criteria and will continue until funds are fully committed.

Signature of Recipient :

Date:

Signature of Parent/Legal Representative:

Relationship to Recipient:

Please provide an email address and phone number for APD to contact you.

Email:

Phone:

What Happens Next:

1. Once you submit your interest form, APD will confirm that you meet all eligibility criteria for the iBudget Florida Waiver. If you do not meet all eligibility criteria, someone from APD will contact you.
2. A team member from APD will contact you to arrange completion of items needed for waiver enrollment. Your active participation is key to successful enrollment.
3. You or your legal representative signs the Home and Community Based Waiver (HCBS) Eligibility Worksheet.
4. You participate in an individualized needs assessment called the Questionnaire for Situational Information (QSI), unless one was already completed within the last three (3) years.
5. APD will coordinate with the Department of Children and Families (DCF) regarding Medicaid eligibility.
6. Individuals approved for enrollment onto the iBudget Florida Waiver will receive an offer letter from APD confirming enrollment with information on how to start receiving services.

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