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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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FOSTER CARE STATUS
IF SELECTED 'PARTICIPANT IS IN FOSTER CARE' ABOVE, PROVIDE THE FOLLOWING INFORMATION, IF KNOWN

PARENT/GUARDIAN/LEGALLY AUTHORIZED REPRESENTATIVE (P/G/LAR) INFORMATION

P/G/LAR First Name Last Name Email Phone Relationship to Child Address City State Zip
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Add P/G/LAR

If applicable, please explain the child’s school or educational/vocational program schedule below, including how many hours a week they attend the program (i.e., Mon-Fri 8am-1pm, etc.). Please also include other standing appointments, e.g., therapy, medical appointments, OT/PT/ST, CFTSS, PDN/PCA/CDPAS, Hospice, etc.

For extracurricular or community activities, in the box above, note how many hours a day, week, or month.

In the box below, please note the Summer Programming schedule if this schedule is different from what is noted in the box above.

Enrollment Information
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FINALIZED LEVEL OF CARE (LOC) STATUS
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HCBS Information

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

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

Maximum file size to upload is 10MB.

Level of Care

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Plan of Care

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Supporting Documentation

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Uploaded Documents
Files 
Type 
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DESCRIBE ANY KNOWN BARRIERS OR OBSTACLES TO THE MEMBER'S GOALS, KNOWN STRATEGIES TO ADDRESS THESE BARRIERS, AND/OR ADDITIONAL INFORMATION/COMMENTS FOR THE HCBS PROVIDER REGARDING THE PARTICIPANT AND THEIR FAMILY AND/OR THE SERVICE(S) REQUESTED.

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Submit