Goals

REFERRED HCBS SERVICE(S)

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COMMUNITY HABILITATION

PREVOCATIONAL SERVICES

DAY HABILITATION

SUPPORTED EMPLOYMENT

CAREGIVER/FAMILY ADVOCACY AND SUPPORT SERVICES

RESPITE SERVICE

PALLATIVE CARE

MASSAGE

COUNSELING AND SUPPORT SERVICES

EXPRESSIVE

PAIN AND SYMPTOM MANAGEMENT

DESIRED GOAL OR NEED TO BE ADDRESSED

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FAMILY PREFERENCES: (MALE/FEMALE STAFF, EVENING HOURS, ETC.)

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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.

CHILD'S FIRST NAME

CHILD'S MI

CHILD'S LAST NAME

MEDICAID CIN #

CHILD’S ADDRESS (#, STREET)

CHILD’S CITY

CHILD’S STATE

CHILD’S ZIP

DATE OF BIRTH

GENDER IDENTITY

PREFERRED CONTACT METHOD

PARENT/GUARDIAN EMAIL

PARENT/GUARDIAN PHONE #

PARENT/GUARDIAN/LEGALLY AUTHORIZED REPRESENTATIVE

PRIMARY LANGUAGE

SECONDARY LANGUAGE

TARGET POPULATION

SERIOUS EMOTIONAL DISTURBANCE(SED)

MEDICALLY FRAGILE (MEDF)

DEVELOPMENTAL DISABILITIES(DD) AND MEDICALLY FRAGILE(MEDF)

DEVELOPMENTAL DISABILITIES(DD) AND FOSTER CARE

REFERRAL TYPE (CHECK ONE ONLY)

INITIAL REFERRAL

(OR)

SUBSEQUENT REFERRAL–REVISION/UPDATE TO THE EXISTING PLAN OF CARE

ENROLLMENT

NAME OF MEDICAID MANAGED CARE PLAN

FINALIZED LEVEL OF CARE (LOC) STATUS

LOC OBTAINED AND VERIFIED IN UAS

DATE OF LOC, IF APPLICABLE

CAPACITY MANAGEMENT APPROVED BY DOH

DATE OF SLOT APPROVED

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

CONTACT'S FIRST NAME

CONTACT'S LAST NAME

CONTACT’S AGENCY NAME

Date

CONTACT'S TITLE

EMAIL ADDRESS

PHONE #

CONTACT ADDRESS

CITY

COUNTY

STATE

Zip

NAME OF DESIGNATED LEAD HEALTH HOME SERVING CHILDREN

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.

HOME AND COMMUNITY BASED SERVICE PROVIDER

PHONE #

HOME AND COMMUNITY BASED SERVICE PROVIDER ADDRESS

ADDITIONAL INFORMATION OR COMMENTS REGARDING THE PARTICIPANT AND/OR THEIR FAMILY:

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.

Maximum file size to upload is 10MB.

Level of Care

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Plan of Care

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		Plan Care upload...

Supporting Documentation

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Uploaded Documents

Files

Type

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ADDITIONAL INFORMATION OR COMMENTS FOR THE HCBS PROVIDER:

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