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New York State Department of Health

Home and Community Based Services (HCBS) to HCBS Provider

Health Home Care Management/C-YES Referral for Home and Community Based Services (HCBS) to HCBS Provider
Medicaid 1915(c) Children’s Waiver Program
SECTION I: To be completed by the HHCM/C-YES. Complete one form per HCBS provider. One form may include all HCBS to be provided by the HCBS provider.

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REFERRAL TYPE (CHECK ONE ONLY)

(OR)

ENROLLMENT
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FINALIZED LEVEL OF CARE (LOC) STATUS
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xv

Name of Care Manager, Care Management Agency and Designated Lead Health Home

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A list of Home and Community Based Service Providers was provided to the child/parent/guardian/legally authorized representative. The child/parent/guardian/legally authorized representative has selected the following agency. The child/parent/guardian/legally authorized representative has chosen the provider below.

PLEASE CLICK ADD AND SELECT SERVICE BEING REQUESTED AND DESIRED GOAL TO BE ADDRESSED FOR EACH SERVICE

Add Service Goal
REFERRED SERVICE(S) 
PALLATIVE CARE 
DESIRED GOAL OR NEED TO BE ADDRESSED 
FAMILY PREFERENCES: (MALE/FEMALE STAFF, EVENING HOURS, ETC.) 
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Level of Care, Plan of Care and Supporting Documentation.

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Level of Care

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Plan of Care

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Supporting Documentation

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