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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

OMH HCBS Children's Waiver
Financial Information Form

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Date:

To:

From:




Operations Support Unit Waiver Staff
OMH Finance Group, 1st Floor, 44 Holland Ave.
HCBS Agency Name

Completed by

Child's Name:

Child's SN:

Child's CIN #:

Child's DOB: Gender:
Directions: Please complete ALL sections and send to OSU with Transmittal 1 for all new enrollments.
Medicaid Status
County of Medicaid
Active Medicaid
Application Pending - Date filed with County
Will Apply
Child's Current Living Situation
Home with: Bio Parent Adoptive Parent
Foster care Other
Placement: No If Yes, placed with
Institution: Psych IP RTF
OMH Residential Programs (SOCR, VOCR, FBT, TFH)
OCFS Residential Program (RTC, Detention Ctr, Therapeutic, Foster)
Anticipated date of discharge from placement:
Note: Needs to be discharged form placement prior to waiver enrollment.
ICM status: ICM enrolled ICM disenrolled
Needs to be disenrolled form ICM prior to waiver application.
U.S. Citizen Status
U.S. Citizen? Yes No
If Non-Citizen:
Date entered U.S.
Is child legal resident? Yes No
Green Card Card #
Child's Country of birth:
SSI Status
SSI: Yes No
SSI Application Pending
Child's Income
Compare child's income to Medicaid income level to ensure child meets Medicaid eligibility.
Child Support: Yes No
If yes, amount per month: $
Other Income: Yes $ No
Child's SSA Benefit: Yes No
If yes, amount per month: $
Note: A Child Receives a SSA child's benefit if a parent is retired, disabled or deceased.
Indicate parents' status:
Retired Disabled Deceased
None of the above apply to either parent
Child Resources:
Amount: $ Type:
Health Insurance
Private Third Party health Insurance
Name:
VA/Military Benefits
Other - Name
None
Legal Custody Status - provide name and address
Birth Parents:
Adoptive Parents:
Foster Care:
Other Custody: Other Family or Legal Guardian:
DSS Custody:
NYC-ACS Involvement? Yes No

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