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

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

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Discharge Plan

Child’s Name and "C"#:   Parent/Guardian:  
Address:   Telephone Number:  
Date of Enrollment:   Date of Disenrollment:  
Name of ICC:   Agency:  
  1. Brief summary of course of treatment (include goals/objectives achieved and description of services received while enrolled in the Waiver):

  2. Discharge services to be provided:
    Service Type Agency Contact Person Telephone Number
  3. Disenrollment procedures (each item must be completed and checked):
    • _____ Team meeting with family, Child, ICC and new providers
    • _____ Telephone coordination of transition with all providers, family child and ICC
    • _____ Individual meetings with ICC, family, child and providers
    • _____ Reminder to family/caregiver of Child Health Plus Re-enrollment process
    • _____ Supervisor reviewed and approved plan
    • _____ Disenrollment form signed by family, LGU and mailed to OSU
  4. Discharge Plan reviewed and approved by:
    Child/Youth:   Date:  
    Parent/Guardian:   Date:  
    ICC:   Date:  
    ICC Supervisor:   Date:  

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