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Office of Mental Health

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

800

HCBS Waiver Program Forms & Reports

Policy

Forms/Reports Purpose Responsibility Timeframe
Safety Alert Plan PDF Document Assists in preventing crises and assuring safety through a signed, proactive agreement between agency, child & family ICC Within Pre-Enrollment period; updated at each review and as needed
HCBS Waiver and Child Safety Contract This is an optional form to be used as ICC's deem useful in assuring that the child understands and agrees with core elements of his/her Safety Alert Plan. ICC Upon completion and revision of Safety Alert Plan.
URF Referral forms Universal Referral Screening Form (URF) PDF Document Request to SPOA to determine services Varies N/A
CANS NY Rating Sheet Assists in assessment of strengths & needs and level of care SPOA/ICC: Screening CANS; ICC: all CANS thereafter

Initial screening, & every 90 days thereafter, upon Waiver disenrollment & as needed

CANS-NY Coding Definitions Coding definitions for the CANS-NY rating sheet. Assists in assessment of strengths & needs and level of care N/A N/A
Algorithms PDF Document Assists in determining level of care SPOA/ICC Whenever CANS is completed
Level of Care (LOC) PDF Document States level of care needed LGU/SPOA Initial screening and annually from date of initial certification
LOC Signature Update Form PDF Document For signature changes to the LGU staff designated to sign the LOC and SP forms LGU N/A
Screening Results Letter Notifies family/caretakers of service determination LGU Initial screening
Application for Participation & Freedom of Choice PDF Document Documents family/caregiver’s choice to participate in the Waiver ICC Initial service planning during TCM or Pre-enrollment
Release of Information PDF Document Allows information concerning child to be released by other providers of services to ICC Agency and ICC Agency to other providers ICC Initial service planning during 30-days prior to Enrollment and ongoing
Medicaid Application Cover Letter PDF Document
MAP formPDF Document NYC Map Form
MAP templatePDF Document NYC only
Cover Letter for the Medicaid Application for child who needs to apply for Medicaid ICC Initial service planning
Child Health Plus Re-Enrollment Information Letter PDF Document Provides family/caregiver with information pertaining to Child Health Plus when child enrolled into waiver. OMH Within 30 days from enrollment
Service Plan Budget PDF Document Lists all Services provided to the youth and anticipated cost, annually. ICC During every Service Plan Review or as needed.
Children Notice to LDSS Re. Loss of Waiver Eligibility PDF Document Informs of loss of Waiver eligibility; Responsibility.

Information found on this form is electronically transmitted by means of CAIRS, and no longer sent to OSU in paper form. This document is available for informative purposes only.

Operations Support Unit and ICC When loss of eligibility information is submitted to OSU
Children's Waiver Transmittal Form with Instructions to Complete/Submit (HTML | PDF Document version) To facilitate Waiver enrollment determinations by OSU.

Information found on this form is electronically transmitted by means of CAIRS, and no longer sent to OSU in paper form. This document is available for informative purposes only.

ICC assures completion of required documentation and submits to OMH's Operations Support Unit who determines eligibility and issues an enrollment date Complete and submit as soon as possible after child/family sign Application/Freedom of Choice form
Children's Waiver Financial Information Form (HTML version | PDF Document version) Provides OSU with financial information required for enrollment determination.

Information found on this form is electronically transmitted by means of CAIRS, and no longer sent to OSU in paper form. This document is available for informative purposes only.

ICC completes and sends with transmittal to OSU As soon as possible after Application/Freedom of Choice form is completed
Choice of Provider Verification Documents that a family has been made aware of the county’s providers of the 5 waiver services and has selected providers ICC Initial Service Planning – during start-up; updated during enrollment
Flex Funds Approval Form PDF Document Document approval of proposed flex expenditure ICC Prior to inclusion in service plan & prior to expenditure
Initial Service Plan Narrative (ISPN) PDF Document Describes child history, child and family strengths, priorities, needs, severity of concerns, and discharge profile. ICC During 30-day period prior to enrollment
90 Day Review Narrative PDF Document
Reviews and updates all aspects, including the budget, of prior service plans ICC Every 90 days from Waiver enrollment date

Goals and Objectives PDF Document

Reviews and updates all aspects, including the budget, of prior service plans ICC At Initial Service Plan and every 90 days from Waiver Enrollment Date.
Progress Notes PDF Document Documents child/family progress towards achieving goals & objectives, child/family contacts, changes in strengths & needs; documents services provided & use of flex dollars ICC On-going
HCBS Waiver Group Progress Notes PDF Document Documents child/family progress towards achieving goals & objectives, child/family contacts, changes in strengths & needs; documents services provided & use of flex dollars Skill Building, Respite, Family Support, Prevocational, and Youth Peer Advocacy ongoing
Discharge Plan PDF Document Summarizes discharge plan ICC Upon disenrollment from Waiver
Aftercare Follow-Up Plan Documents discharge follow-up activities ICC or designee After disenrollment
Inpatient Hospitalization Tracks number of days Waiver child is hospitalized, if any ICC Agency On-going
Administrative Review (*note new name of revised report) Describes in detail administration of the Waiver Program in each ICC Agency
Documents will be issued annually by OMH-Central Office
ICC Agency Annually (within 30 days preceding scheduled annual site visit)
Site Visit Tool Agency
Documents will be issued annually by OMH-Central Office
Site Visit Tool ISP PDF Document
Documents results of annual site visits to ICC Agencies OMH Regional Field Coordinators Annually – within 30 days of site visit
Performance Improvement Plan PDF Document Documents plans for corrective actions cited in surveys/audits ICC Agency Within 30 days of receipt of site visit summary
HCBS Waiver Qualification Form: ICC ProviderPDF Document ICC Agency application to be provider LGU As needed
HCBS Waiver Qualification Form: SubcontractorPDF Document Subcontractor application to be part of network LGU As needed
Consolidated Budget Report Establishes agency contractual agreement with OMH and continued approval to operate HCBS Waiver program ICC Agency Initially and annually
Contracts Varied LGU/ ICC Agency Varies
ICC Tracker Log (Sample) Track qualifying face-to-face ICC contacts ICC Monthly

* OSU = Operations Support Unit, OMH
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Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.