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

OMH HCBS Children's Waiver
Transmittal Form - New Enrollments with
Instructions to Complete/Submit

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OVERVIEW: In order to determine the effective date of enrollment and issue the Notice of Acceptance, the Operations Support Unit (OSU) must receive copies of all of the following completed/signed/approved/dated documents:

These forms are sent to OSU using the Transmittal Form - New Enrollments.  The required completed forms and the Transmittal form should be sent to OSU as soon as possible after completion.  It is anticipated that for most cases materials will be sent to OSU in two groups using the Transmittal Form each time.  For Transmittal Group 2, copy the completed Transmittal 1 for the child and complete the portion designated for Transmittal 2.
Note: If everything is completed and signed during the initial meeting with the family, then all forms can be sent to OSU at the same time. DO NOT delay sending the application/referral/LOC forms while you are waiting for approval of the service plan and budget. However, this situation is believed to be the exception rather than the rule.

Who/How Complete: The ICC Supervisor is responsible for completing, signing and dating the Transmittal form and sending all required forms to OSU. If the transmittal is not fully and legibly completed and all required documents are not enclosed and/or are not properly dated and signed, OSU will return the Transmittal to the ICC Supervisor to obtain the missing or incomplete information.  The case will not be processed until the missing/incomplete information, including missing signatures, is received by OSU.
Header of Form:  Should be self-explanatory. 
Body of Form: ● Complete the box on the left hand side of the form. ● Enter the date specified in the box next to each form. ● Print and sign the Supervisor’s name. ● The supervisor must be on an OSU list of approved Supervisors. ● The box on the right hand side of the form (Header is shaded) is for OSU use to request missing/incomplete information from an ICC Supervisor.

When to Send:
Transmittal Group 1 - send immediately after the child/family signs the Application/Freedom of Choice form
Transmittal Group 2 - send as soon as the Service Plan and Budget have been approved/signed by the SPOA or LGU.
Note: If a Medicaid Application (MA) is necessary, it can be forwarded to OSU in Transmittal 1 or 2.  It will depend on when the MA application is completed and filed with the LDSS/HRA.

Send to: Attach copies of the required documents to the original Transmittal form and send to:

NYS Office of Mental Health
Finance Group, Operation Support Unit
44 Holland Avenue, First Floor
Albany, NY 12229
Attention: Stephanie Wollman (HCBS Waiver)

Rev: 10/20/08

OMH HCBS Children's Waiver
Transmittal Form - New Enrollments

To:
Operations Support Unit (Waiver Staff)
OMH Finance Group, 1st Floor, 44 Holland Avenue, Albany, NY 12229
From:

Re:



HCBS Agency Name

Child's Name (LN, FN, MI)

County

Medicaid ID #

Directions: ICC Supervisor completes/dates/signs transmittal form. Attaches copies of required documents to original of transmittal form and sends to address shown above. Transmittal will be returned to ICC Supervisor if all required documents are not enclosed and/or are not properly dated and signed.
Transmittal 1
Required Documents
Date Returned to ICC supervisor by OSU
to obtain missing/incomplete information
1 Application/Freedom of Choice
Note: Requires Witness
Date signed:

Date returned to ICC
supervisor:
Mailed Faxed

Transmittal 1 or 2 will not be
processed until all requested
information is received by OSU

Please correct and return to OSU:

Signature(s) Missing
 _________________________________
 _________________________________

Signature(s) Missing
 _________________________________
 _________________________________

Signature(s) Missing
 _________________________________
 _________________________________

Signature(s) Missing
 _________________________________
 _________________________________

Signature(s) Missing
 _________________________________
 _________________________________

2 Financial Information Form Completed &
Date signed:
3 Level of Care
Note: Needs 2 Signatures
Date signed:
4 Medicaid Application* Date filed
with county
Name of ICC Supervisor
Sign: _______________
Print:
Date signed:

Transmittal 2
Required Documents
Date
4 Medicaid Application* Date signed:
5 Initial Service Plan Date signed:
6 Budget Completed
(No date
required)
Name of ICC Supervisor
Sign: _______________
Print:
Date signed:

*Medicaid (MA) Application is not necessary if child is already eligible for Medicaid at time s/he applies for Waiver. If no MA application is necessary, write N/A in date box. If MA application is necessary, it can be sent with either transmittal 1 or 2 depending on when MA application is completed and delivered to county LDSS.

Rev: 09/15/08

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