Form Ocfs 8000 PDF Details

In the landscape of child welfare and healthcare services within New York State, the OCFS-8000 form emerges as a crucial document, facilitating a bridge between children in need and the comprehensive services offered by the Bridges to Health (B2H) Home & Community Based Services Medicaid Waiver Program. This form serves as a referral mechanism for children deemed to benefit from the program due to their specific health or psychological needs, categorized under Serious Emotional Disturbance (SED), Developmental Disabilities (DD), or Medically Fragile (MedF) Waivers. Through this form, detailed information about the child in question, including their name, date of birth, Medicaid CIN number, and chosen health care integration agency, is collected. This process ensures that the Local Department of Social Services (LDSS) or Division of Juvenile Justice and Opportunities for Youth (DJJOY) can effectively communicate the child's needs and eligibility to the appropriate service providers. Additionally, the form operates as a conduit for further action, requiring accompanying authorization for the release of information and, when pertinent, diagnosis and supporting documents to substantiate the referral. This structured approach not only simplifies the referral process but also underscores the state's commitment to integrating vulnerable children into programs tailored to address their unique health and emotional challenges, thereby reflecting a systematized effort towards healthcare and social service integration within New York State.

QuestionAnswer
Form NameForm Ocfs 8000
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesocfs training forms, ocfs forms 5451, ocfsery ocfs trainings, ocfs remote learning exemption form

Form Preview Example

OCFS-8000 (1/2011)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

REFERRAL FORM

BRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM

CHILD’S NAME (LAST, FIRST, MI,):

DATE OF BIRTH:

SEX:

 

 

MEDICAID CIN #:

 

Male

Female

 

 

 

 

 

 

 

B2H WAIVER TYPE (Check one only)

 

REFERRAL TYPE (Check one only)

B2H Serious Emotional Disturbance (SED) Waiver

Initial Referral

B2H Developmental Disabilities (DD) Waiver

 

Subsequent Referral: completed if child name is on Wait List

B2H Medically Fragile (MedF) Waiver

 

 

 

 

 

 

 

 

A list of Health Care Integration Agencies was provided to the child/medical consenter. The child/medical consenter has selected the following agency:

HEALTH CARE INTEGRATION AGENCY NAME:

 

PHONE #:

 

 

 

 

 

HEALTH CARE INTEGRATION AGENCY ADDRESS:

CITY:

STATE:

ZIP CODE:

 

 

 

 

HEALTH CARE INTEGRATION AGENCY STAFF CONTACT NAME:

 

 

 

 

 

 

 

The

 

has determined that the child

 

LOCAL DEPARTMENT OF SOCIAL SERVICES (LDSS) OR DIVISION OF JUVENILE JUSTICE AND

 

OPPORTUNITIES FOR YOUTH (DJJOY)

identified above would benefit from the services offered by the B2H Medicaid Waiver Program. The child is Medicaid eligible. For a child in LDSS custody, we have assigned a role to their CONNECTIONS Family Services Stage.

To assist in your assessment of the child’s suitability for the B2H Medicaid Waiver Program, we have included the following items:

Authorization for Release of Information form(s), (OCFS-8001)

B2H Medicaid Waiver Program Qualifying Diagnosis(es) and supporting documentation.

For a Subsequent Referral, all information from Initial Referral and Initial Application is included.

MEDICAL CONSENTER NAME:

 

RELATIONSHIP TO CHILD:

 

 

 

 

 

 

 

 

MEDICAL CONSENTER ADDRESS:

CITY:

 

STATE:

ZIP CODE:

PHONE #:

 

 

 

 

 

 

LOCAL DEPARTMENT OF SOCIAL SERVICES OR

DIVISION OF JUVENILE JUSTICE AND OPPORTUNITIES FOR YOUTH (DJJOY)

CONTACT INFO (Check One)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT’S NAME:

 

CONTACT’S SIGNATURE:

 

 

 

 

DATE:

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT’S TITLE:

 

 

 

 

 

PHONE #:

 

 

 

 

 

 

 

 

 

 

CONTACT’S ADDRESS:

 

 

CITY:

COUNTY:

 

STATE:

ZIP CODE:

 

 

 

 

 

 

 

 

 

 

Original – Health Care Integration Agency; Copy of 8000 Form Only – Child/Medical Consenter, Caregiver, Case Planning Agency, OCFS Quality Management Specialist; Copy of 8000 Form and Supporting Documentation - Local Department of Social Services or Division of Juvenile Justice and Opportunities for Youth

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ocfs 5014 s form empty fields to consider

Write down the details in the MEDICAL CONSENTER NAME, RELATIONSHIP TO CHILD, MEDICAL CONSENTER ADDRESS, CITY, STATE, ZIP CODE, PHONE, LOCAL DEPARTMENT OF SOCIAL, DIVISION OF JUVENILE JUSTICE AND, CONTACT INFO Check One, CONTACTS NAME, CONTACTS TITLE, CONTACTS SIGNATURE X, DATE, and PHONE area.

ocfs 5014 s form MEDICAL CONSENTER NAME, RELATIONSHIP TO CHILD, MEDICAL CONSENTER ADDRESS, CITY, STATE, ZIP CODE, PHONE, LOCAL DEPARTMENT OF SOCIAL, DIVISION OF JUVENILE JUSTICE AND, CONTACT INFO Check One, CONTACTS NAME, CONTACTS TITLE, CONTACTS SIGNATURE X, DATE, and PHONE blanks to complete

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