Are you looking for a new way to track your monthly expenses? If so, you may want to consider using Form Ocfs 8000. This form is designed to help you keep track of your spending each month, and it can be a great way to stay on top of your finances. In this post, we'll discuss what Form Ocfs 8000 is and how you can use it to improve your financial situation. We'll also provide a few tips on how to fill out the form correctly.
This page holds information about form ocfs 8000. Our advice is that you check out this information before you decide to start working with the file.
| Question | Answer |
|---|---|
| Form Name | Form Ocfs 8000 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ocfs forms 5451, ocfs training, ocfs ccfs le 008 form, ocfs forms ny |
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),
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