Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

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HCBS Waiver Qualifications Form: ICC Provider

A) Identification of applicant:

B) Check the service(s) you wish to provide in addition to Intensive Care Coordination (ICC):

• Intensive In Home
• Crisis Response
• Skill Building
• Respite Hourly
• Respite Overnight
• Family Support

C) List all current licenses, contracts, approved programs, and certifications (include Medicaid numbers where appropriate): 

If none are current, list those operative in the past:

D) Describe other agency affiliations demonstrating agency effectiveness in interagency cooperative ventures:

E) Describe agency’s ability to serve SED children:

Note: For first time applicants, a detailed narrative describing the agency must be additionally completed and attached. Please include mission, history and populations served.

I certify that the summary information submitted is accurate and true to the best of my knowledge.

Note: The LGU must send this form along with a written recommendation to:
Gary Hook, HCBS Waiver Coordinator
OMH Division of Children and Families, 6 ^th Floor
44 Holland Avenue
Albany, NY12229

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.