Revenues Service Code Unit Type Hours/Units Frequency Rate Total Funding During Auth Period
Authorized Service Unit Type Hours/Units Frequency Unit Rate Cost
Expenses Unit Type Hours/Units Frequency Pay Rate Expense Type Adjusted Rate Expected Cost (Auth Period)
Unallocated Dollars
Total Expected Cost During Auth Period

GT Independence

Budget Calculator

Florida Budget Tool

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Affiliates to fund or authorize services. This budget will be determined under the Budget Authority model which means that any adjustments in rate will modify available budget hours.


Member Name:
Authorization Begin: Authorization End: Start Date:


GT Independence

Florida Budget Authorization Sheet

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Affiliates to fund or authorize services. This budget will be determined under the Budget Authority model which means that any adjustments in rate will modify available budget hours.


Member Name: Begin Date: End Date:

Agency: Agency Code:

Cost Summary By Year

Total

Cost Summary By Authorization Period

Total

Cost Summary By Month

Total

Workers Compensation for Agency with Choice is rolled into each direct service, adding a percentage to the rate. It is not shown separate on this sheet


Member/Authorized Representative Signature: ________________________________________________ Date:____________________


Budget Sheet - Self Determination


Expense Unit Type Hours/Units Frequency Payrate Expected Cost
Total

By my signature I acknowledge that I have been given a copy of my budget.


Member/Authorized Representative Signature:________________________________________________ Date:____________________



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