Notification Of Foster Care Level Of Care And Room And Board printable pdf download

OCFS-LDSS-7018 (Rev. 04/2008)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

NOTIFICATION OF FOSTER CARE LEVEL OF CARE AND ROOM and BOARD PAYMENT

NOTICE

NAME AND ADDRESS OF LOCAL SOCIAL SERVICES DISTRICT OR

VOLUNTARY AUTHORIZED AGENCY:

DATE:

CASE NUMBER

CHILD’S CIN NUMBER

FOSTER PARENT’S NAME AND ADDRESS

(

)

To Request a Conference

(

)

To Request Record Access Once a Fair

Hearing has been Requested

OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

Listed below is the level of care determination and the rate of room and board payment that will be made to you on behalf of

the foster child placed in your care. The effective date is listed below.

Name of child

Date of placement of the child in your foster home

Level of care and rate of foster care room and board payment:

The rate of the foster care room and board payment for your foster child is based on the level of care determination checked

below (normal, special or exceptional).

If you disagree with the level of care determination checked below for your foster

child, you have a right to appeal the decision by using the procedures listed on the reverse of this form. You are entitled to a

new notice if the level of care determination for your foster child (normal, special or exceptional) is changed.

Normal – The child has no diagnosed physical or mental condition requiring special or exceptional care, although he or

she may have problems relating to neglect, maltreatment, or lack of care.

Special – The child has a pronounced physical condition certified by a physician as requiring a high degree of physical

care; OR is awaiting a family court hearing on a Person in Need of Supervision (PINS) or Juvenile Delinquency (JD) petition

or has been adjudicated as a PINS or JD; OR has been diagnosed by a qualified psychiatrist or psychologist as moderately

developmentally disabled, emotionally disturbed, or with a behavior disorder requiring a high degree of supervision; OR is a

refugee or Cuban/Haitian entrant and is unable to function successfully because of factors related to that status; OR entered

foster care directly from inpatient hospital care within the past year. {Note: Four hours of training required annually}

Exceptional – The child requires 24-hour-a-day care by a qualified nurse or someone supervised by a qualified nurse

or physician, as certified by a physician ; OR has severe behavior problems involving violence and has been certified by a

qualified psychiatrist or psychologist as requiring a high level of individual supervision in the foster home; OR has been

diagnosed by a qualified physician as having severe mental illness, severe developmental disabilities, brain damage or

autism; OR has been diagnosed by a physician as having AIDS or HIV-related illness (up to one year if child tests positive

for HIV and then subsequently test negative for HIV). {Note: Five hours of training required annually}

Amount of foster care room and board payment is $

per day, effective

The actual rate you will receive may be different than the rate listed above. The rate amount may change over time due to

circumstances other than the foster child’s level of care determination. These rate amounts may change due to the foster

child’s age, state rate changes and other changes allowed by law.

For special and exceptional rates, the child’s qualifying condition or circumstance is identified as:

The regulation that governs the special and exceptional rate setting process is 18 NYCRR 427.6.

YOU HAVE THE RIGHT TO APPEAL THIS DECISION. BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO

APPEAL THIS DECISION.

Worker Signature/Date:

Supervisor Signature/Date:

Notification Of Foster Care Level Of Care And Room And Board

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