Skip to Main Content
NY.gov Portal State Agency Listing Search all of NY.gov
Commissioner Michael F. Hogan, PhD
Governor Andrew M. Cuomo

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

800

HCBS Waiver Program Forms & Reports

Policy

To view or print PDF files, Adobe Acrobat Reader must be installed on your computer. Download Adobe Acrobat Reader.

Forms/Reports Purpose Responsibility Timeframe Source & Chapter Reference
Safety Alert Plan (PDF) Assists in preventing crises and assuring safety through a signed, proactive agreement between agency, child & family ICC Within start-up period; updated at each review and as needed OMH /400
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. 400.2
URF Referral forms Universal Referral Screening Form (URF) Request to SPOA to determine services Varies N/A Local – form may vary/300
CANS MH Assists in assessment of strengths & needs and level of care SPOA/ICC: Screening CANS; ICC: all CANS thereafter Initial screening, 30-Day Service Plan Review & every 180 days thereafter, upon Waiver disenrollment & as needed OMH/400
Algorithms Assists in determining level of care SPOA/ICC Whenever CANS is completed OMH/400
Level of Care (LOC) States level of care needed LGU/SPOA Initial screening and annually from date of initial certification OMH/300 & 500
Screening Results Letter Notifies family/caretakers of service determination LGU Initial screening OSU/500
Application for Participation & Freedom of Choice Documents family/caregiver’s choice to participate in the Waiver ICC Initial service planning during start-up OSU/500
Release of Information (PDF) 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 start-up and ongoing OMH Central Office/400
Medicaid Application Cover Letter Cover Letter for the Medicaid Application for child who needs to apply for Medicaid ICC Initial service planning start-up period OSU/500
Application for Medical Assistance Application for Medical Assistance ICC/family Initial service planning start-up period OSU/500
Notice of Medicaid Decision (response to Medicaid application) Confirms LDSS determination of child’s Medicaid eligibility LDSS Within 60 days LDSS/500
Acceptance, Denial, or Termination letter (notice of Waiver decision) Notifies family/child of Waiver enrollment status and informs of right to fair hearing. The 30-Day Service Plan Review is due 30 days from the enrollment date on the Acceptance letter. OMH - OSU Varies OSU/500
Children Notice to LDSS Re. Loss of Waiver Eligibility (PDF) Informs of loss of Waiver eligibility; Responsibility Operations Support Unit and ICC When loss of eligibility information is submitted to OSU Chapter 500
Children's Waiver Transmittal Form with Instructions to Complete/Submit (HTML | PDF) To facilitate Waiver enrollment determinations by OSU 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 Chapter 500
Children's Waiver Financial Information Form (HTML | PDF) Provides OSU with financial information required for enrollment determination ICC completes and sends with transmittal to OSU As soon as possible after Application/Freedom of Choice form is completed Chapter 500
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 ICC Agency develops form listing all Waiver providers/400
Flex Funds Approval Form Document approval of proposed flex expenditure ICC Prior to inclusion in service plan & prior to expenditure 400.6
Initial Service Plan Narrative (ISPN) (PDF) Describes child history, child and family strengths, priorities, needs, severity of concerns, and discharge profile. ICC During start-up period OMH/400

30 Day Review Narrative 90 Day Review Narrative

 Reviews and updates all aspects, including the budget, of prior service plans ICC At 30 days from Waiver enrollment date issued by OSU and every 90 days thereafter throughout the Waiver enrollment OMH/400

Goals and Objectives (PDF)

Reviews and updates all aspects, including the budget, of prior service plans ICC At 30 days from Waiver enrollment date issued by OSU and every 90 days thereafter throughout the Waiver enrollment OMH/400
Progress Notes
(HTML) (PDF)		 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 OMH /400
HCBS Waiver Group Progress Notes
(HTML) (PDF)		 Documents child/family progress towards achieving goals & objectives, child/family contacts, changes in strengths & needs; documents services provided & use of flex dollars SKill Builders, Family Support Service workers, Respite workers ongoing OMH /600
Letter to Hospital Requests information related to hospitalized Waiver enrollee ICC Upon and during hospitalizations OMH/400
Transfers County to County Provides continuation of care when enrollee moves from one county to another ICC’s in both agencies if agency change is also involved Upon enrollee confirmation of moving OSU/500
Discharge Plan Summarizes discharge plan ICC Upon disenrollment from Waiver OMH /400
Aftercare Follow-Up Plan Documents discharge follow-up activities ICC or designee After disenrollment OMH /400
Admission Record Provides demographic & clinical information ICC Agency Within 30 days of enrollment CAIRS/700
Six-Month Follow-Up Provides additional information as a follow-up to the Child/Family Initial Description to assess change over time& in relation to services provided ICC Agency At each six-month interval during child’ enrollment CAIRS/700
Child Discharge from HCBS Waiver Demonstrates change over time and final status at discharge ICC Upon discharge CAIRS/700
Youth Assessment of Care Provides for a measurement of youth satisfaction ICC Agency Annually OMH /700
Parent Assessment of Care Provides for a measurement of family satisfaction ICC Agency Annually OMH /700
Inpatient Hospitalization Tracks number of days Waiver child is hospitalized, if any ICC Agency On-going CAIRS/700
Flexible Service Funds Expenditures Documents flex fund expenditures for each child and each program ICC Agency Quarterly CAIRS Quarterly Program Specific Fiscal Report/700
In-Kind Community Services Child & program specific; lists services provided by community resources & not billed to Medicaid ICC Agency Quarterly CAIRS Quarterly Program Specific Fiscal Report/700
Start-Up ICC Child & program specific; documents units of waiver services provided during Waiver Start-Up period (1st 30 days) through ICC rate ICC Agency Quarterly CAIRS Quarterly Program Specific Fiscal Report/700
Inpatient ICC Identifies the total units of ICC service provided through ICC while enrollee is hospitalized per program per child ICC Agency Quarterly CAIRS Quarterly Program Specific Fiscal Report/700
Waiver Subcontractor Services Summary Identifies which subcontractors are used, frequency, and costs ICC Agency

Semi-Annually (due in September of current year & March of following year)

CAIRS/700
Administrative Review (*note new name of revised report) Describes in detail administration of the Waiver Program in each ICC Agency ICC Agency Annually (within 30 days preceding scheduled annual site visit) OMH/300 & 700
Semi-Annual Program Report Provides information regarding specific program operations ICC Semi-Annually CAIRS/700
Site-Visit Summary Form Documents results of annual site visits to ICC Agencies OMH Regional Field Coordinators Annually – within 30 days of site visit OMH /700
Plan of Corrective Actions (POCA) Documents plans for corrective actions cited in surveys/audits ICC Agency Within 30 days of receipt of site visit summary OMH /700
Recommendation of Subcontractor to OMH Describes criteria for recommending an organization/individual to provide one or more of the 5 services LGU Start- up & as needed OMH /200
HCBS Waiver Qualification Form: ICC Provider ICC Agency application to be provider LGU As needed OMH m/200
HCBS Waiver Qualification Form: Subcontractor Subcontractor application to be part of network LGU As needed OMH /200
Consolidated Budget Report Establishes agency contractual agreement with OMH and continued approval to operate HCBS Waiver program ICC Agency Initially and annually www.omh.ny.gov/omhweb/spguidelines/
Contracts Varied LGU/ ICC Agency Varies www.omh.ny.gov/omhweb/spguidelines/
Expenditure Reports Varied DOH/OMH Varies OMH/700
OMH Routine Reports: agency, region, county, client Varied OMH Varies CAIRS/700
Request for Services (RFS) to announce the opportunity for agencies to subcontract with the HCBS ICC agency; LGU as needed chapter 200.2

* OSU = Operations Support Unit, OMH

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