Nebraska Medicaid Program Request For Prior Authorization Of Payment Glucagon-Like Peptide-1 Receptor Agonists (Glp-1 Ra) Form printable pdf download

Nebraska Medicaid Program Request For Prior Authorization Of Payment Glucagon-Like Peptide-1 Receptor Agonists (Glp-1 Ra) Form

Instructions for Executing a Restricted Account “Freeze” Letter of Agreement:

Pursuant to T.C.A. 34-1-105(b)(4), by agreement, and with court authorization, certain funds may

be held in a restricted account with a company in lieu of posting a Surety Bond with the Clerk.

On the financial institution’s corporate letterhead, an authorized agent for the depositing financial

institution must state to the Court that “the funds they are holding on behalf of the Ward (and/or

Estate) will be held in a restricted account and that no funds will be withdrawn, for any reason,

without specific approval of the Court”. This statement should further acknowledge that the

financial institution “will hold the funds in a restricted account and will continue to do so even if

the financial institution is merged or acquired by another company”. It should further state that

“any and all changes to this restricted account must be approved by the Court”.

Other items which must be included are as follows:

1. the name of the Respondent;

2. the account number set up to hold the funds;

3. the amount of the funds being held; and

4. the name, address, phone number and signature of the authorized agent.

If available, a corporate seal of the financial institution should also be placed on the letter.

This Letter of Agreement to Restrict Funds should be submitted to the Clerk’s Office along with

the Order appointing the Guardian.

The Order should direct the Clerk to issue Letters of Guardianship upon the approval by the

Judge of the Letter of Agreement from the financial institution.

No Letters of Guardianship will be issued by the Clerk without the approval of this Letter of

Agreement by the Judge.

Be sure to explain to your client that simply because funds are being held by the financial

institution in a restricted account does not mean that Annual Accountings are waived.

Nebraska Medicaid Program Request For Prior Authorization Of Payment Glucagon-Like Peptide-1 Receptor Agonists (Glp-1 Ra) Form