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Office of Mental Health

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

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Form 900 MED (MH) (6-08) State of New York Office of Mental Health

Home and Community Based Services Waiver

Screening Form For ICC Agency

Child's Name (Last, First, M.I.) File No.
Gender Date of Birth
Waiver Program Name Location
1. Criteria: Indicate whether the Child meets any of the following eligibility criteria. Check all that apply, supply details an appropriate.
  • Age is between 5 and 18 years of age.
  • Has a Mental Illness and Meets the definition for Serious Emotional Disturbance.
    Psychiatric Diagnosis:
  • Currently resides in an institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, and has resided in such a hospital for at least 180 consecutive days, or
  • Had resided in an institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, within the past 6 months and was hospitalized for at least 30 consecutive days, or
  • Is eligible for institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, which provides intermediate or long-term care and treatment,
  • Has applied for institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, which provides intermediate or long-term care and treatment.

Hospital name and dates of service that fulfill requirement:

Demonstrates complex health or mental health care needs (relies on Mental Health care, nursing care, monitoring or prescribed medical or Mental Health therapy in order to maintain quality of life). Receives (or appears to need to receive) medical or Mental Health therapies, care or treatments:

  • that are designed to replace or compensate for a vital functional limitation or
  • to avert an immediate threat to life;
  • that are expected to extend beyond 12 months.
  • Appears to be capable of being cared for in the community if provided access to, but not limited to, the following services: Individualized Care Coordination, Intensive In-Home Services, Respite Care, Skill Building Services, Family Support Services, Crisis Response Services.
  • Appears to have service and support needs that cannot be met by one agency/system.
  • Appears to have a viable and consistent living environment with parents/guardians who are able and willing to participate in the Home and Community Based Services waiver and support the child in the home and community.
  • Appears to meet the Medicaid eligibility requirements.
Other Comments:
2. Potential Eligibility/Need for Service:
  • Yes The child appears to be eligible to apply for waiver services.
  • No The child is not eligible to apply for waiver services.
3. Individualized Care  Coordinator Signature: Include signature, title and date.
Signature/Title: Date: