Result of Screening
The referral packet of your child , has been screened and reviewed. It appears that he/she
- Does meet the clinical eligibility criteria to apply for HCBS waiver services.
You will be contacted by the ICC agency to explain the meaning of this decision and to begin formal application to the home and community-based services waiver if you so choose.
- Does not meet the clinical eligibility criteria for the following reasons:
- Is not between the ages of 5 and 18
- Does not meet criteria for serious emotional disturbance
- Does not require, or is not in imminent risk of needing, psychiatric inpatient services
- Does not have complex health or mental health needs
- Has service and support needs that can be met by a single agency/system
- Is not capable of being cared for in the community if provided access to HCBS Waiver service.
- Does not appear to have a viable and consistent living environment with a parent/guardian who is willing to___________________________________ participate in the HCBS Waiver and support the child in the home and community.
Meeting the above stated clinical eligibility criteria is a requirement for applying for HCBS waiver services. It appears that you/your child does not meet the level of care requirements necessary for application. Based on this determination, without further contact from you, the ICC agency will close your referral. However, if desired, you may submit additional information and request a redetermination of the level of care -or- you may choose to continue with the application process*. If you choose to exercise either of these options, please contact the ICC agency at _______________________________ within 10 business days of the receipt of this notice. (*Please note that continuing with the application without furnishing additional information that is substantially different from that furnished in the original referral packet is not likely to result in an outcome different from the result documented in this letter.)
Individualized Care Coordinator
Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.