Application Form For Enrollment - Ocfs - New York State

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OCFS-8004 (1/2011)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
APPLICATION FORM FOR ENROLLMENT
BRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM
CHILD’S NAME, (LAST, FIRST, MI,):
SEX:
DATE OF BIRTH:
MEDICAID CIN #:
DATE OF REFERRAL:
Male
Female
B2H WAIVER TYPE (Check one only):
APPLICATION TYPE (Check one only):
B2H Serious Emotional Disturbance (SED) Waiver
Initial Application
B2H Developmental Disabilities (DD) Waiver
Re-application: completed if child’s name is on the Wait List.
B2H Medically Fragile (MedF) Waiver
INSTRUCTION: The Health Care Integration Agency (HCIA) is responsible for completing Section 1 OR 2 and returning this form
within 60 days of receipt of the completed referral packet.
SECTION 1 – Child Meets Criteria
SECTION 2 – Child Fails to Meet Criteria
The identified child above meets all of the eligibility criteria
The child identified above fails to qualify for the B2H
for participation in the B2H Medicaid Waiver Program and
Medicaid Waiver Program for the following reason(s):
the following documents are attached:
(attach supporting documentation):
Level of Care Form (OCFS-8005A, OMRDD HCBS Level of
Care Form 02-02-97 or OCFS-8005C) completed and
signed,
Individualized Health Plan (IHP) (OCFS-8017) completed
and signed (If budget in IHP is over $51,600 , send a copy
of IHP to Office of Children and Family Services Regional
Office Quality Management Staff),
Freedom of Choice Form (OCFS-8003) completed and
signed,
Health Care Integrator Selection Form (OCFS-8007)
completed and signed,
Waiver Participant’s Rights Form (OCFS-8008) completed
and signed.
Health Care Integration Agency Information (HCIA):
HCIA REPRESENTATIVE NAME:
HCIA REPRESENTATIVE SIGNATURE:
DATE:
X
HCIA NAME:
PHONE #:
HCIA ADDRESS
CITY:
STATE:
ZIP CODE:
DECISION SECTION
FOR
LOCAL DEPARTMENT OF SOCIAL SERVICES (LDSS) OR
DIVISION OF JUVENILE JUSTICE AND OPPORTUNITIES FOR
YOUTH (DJJOY) USE ONLY – COMPLETE DECISION SECTION AND RETURN ORIGINAL TO HCIA
Date Received:
Time Received:
:
am
pm
Initial Application Decision (Check one only):
Request for B2H Medicaid Waiver Program Approved, slot available; complete Notice of Decision – Authorization, (OCFS-8009)
Request for B2H Medicaid Waiver Program Approved, no slot available; complete Wait List Notification Form, (OCFS-8012)
Request for B2H Medicaid Waiver Program Denied; complete Notice of Decision – Denial of Enrollment, (OCFS-8010A)
Date of Decision:
Time of Decision:
:
am
pm
Re-Application Decision (Check one only):
Request for B2H Medicaid Waiver Program Approved; complete Notice of Decision–Authorization, (OCFS-8009)
Request for B2H Medicaid Waiver Program Denied; complete Notice of Decision – Denial of Enrollment, (OCFS-8010A)
Date of Decision:
Time of Decision:
:
am
pm
CONTACT’S NAME:
CONTACT’S SIGNATURE:
DATE:
X
CONTACT’S TITLE:
CONTACT ADDRESS:
CITY:
COUNTY:
STATE:
ZIP CODE:
Original – Health Care Integration Agency; Copy of Completed 8004 Form Only – Child/Medical Consenter, Case Planning
Agency, Caregiver, OCFS Regional Quality Management Specialist; Copy of 8004 and Supporting Documentation – Local
Department of Social Services or Division of Juvenile Justice and Opportunities for Youth

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