Service Summary Form - Ocfs - New York State

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OCFS-8018 (1/2012)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
SERVICE SUMMARY FORM
BRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM
INSTRUCTION: To be completed by the Health Care Integrator (HCI) or Waiver Service Provider (WSP). Submit copy
to Health Care Integration Agency (HCIA).
CHILD’S NAME, (LAST, FIRST, MI,):
SEX:
DATE OF BIRTH:
MEDICAID CIN #:
Male
Female
B2H WAIVER TYPE (Check one only)
B2H Serious Emotional Disturbance (SED) Waiver
B2H Developmental Disabilities (DD) Waiver
B2H Medically Fragile (MedF) Waiver
AM
AM
DATE OF SERVICE:
START TIME:
PM
END TIME:
TOTAL BILLABLE UNITS:
PM
Service Location:
A. Waiver Services
B. Individual C. Group
D Services Planning
E. Billable Unit
(Check ONE Service Only)
(Max Billing per 6 mos.)
Regular Full Month (Per one month)
Health Care Integration
Enrollment Month (Per one month)
Location of Service:
In Home
HCIA transfer from original HCIA
Other
(Per half month)
HCIA transfer to a New HCIA
(Per half month)
Hospitalization from 1-10 days
(Per one month)
Hospitalization from 11-30 days
(Per one month)
Family/Caregiver Supports &
1 Hour
Per 15 min. unit
Services
Skill Building
1 Hour
Per 15 min. unit
Day Habilitation
2 Hours
Per 1 hour unit
Special Needs Community
2 Hours
Per 15 min. unit
Advocacy & Support
Prevocational Services
2 Hours
Per 1 hour unit
Supported Employment
2 Hours
Per 1 hour unit
Planned Respite
1 Hour
Full day respite rate (4 or more hours)
Less than full day rate (if less than 4
hours)
Crisis Avoidance,
2 Hours
Per 15 min. unit
Management & Training
Immediate Crisis Response
2 Hours
Per 15 min. unit
Services
Intensive In-home Supports
2 Hours
Per 15 min. unit
& Services
Crisis Respite
1 Hour
Full day respite rate (4 or more hours)
Less than full day rate (if less than 4
hours)
Using the chart above, calculate your TOTAL BILLABLE UNITS based upon start and end times.
SEE B2H WAIVER RATE CODE MATRIX AND CHAPTER 13 OF THE B2H PROGRAM MANUAL FOR BILLING INFORMATION

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