Home and Community Based Services Waiver
Division of Children and Families
HCBS Waiver Qualifications Form: ICC Provider
A) Identification of applicant:
|Agency (business) name:|
|Name:||Phone #: ( )|
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
Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.