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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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HCBS Waiver Qualifications Form: ICC Provider

A) Identification of applicant:

Agency (business) name:
 
Address:
 
Contact person:
 
Name: Phone #: ( )

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

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.

Signature of Authorized Agency Representative & Date:
Print Name and Title

Note: The LGU must send this form along with a written recommendation to:
Joyce Billetts, 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.