Form Ocfs 8018 PDF Details

The OCFS-8018 form plays a critical role within New York State's Office of Children and Family Services, specifically within the Bridges to Health (B2H) Home & Community Based Services Medicaid Waiver Program. Designed to be filled out by Health Care Integrators (HCI) or Waiver Service Providers (WSP), this document captures essential information pertaining to the services provided to children under the program. It serves as a comprehensive report, including the child’s name, date of birth, sex, Medicaid CIN #, and the type of B2H Waiver—categorizing the child’s needs as Serious Emotional Disturbance (SED), Developmental Disabilities (DD), or Medically Fragile (MedF). The form further requires documentation of service dates, times, the total billable units, service location, and the specific waiver services provided. Additionally, it compels the service provider to describe the service rendered and the child's response to the intervention, thus tracking progress and ensuring accountability. A notable section requires the signature of both the provider and their supervisor, along with contact information for the Health Care Integration Agency (HCIA), highlighting the collaborative approach in managing the child's healthcare needs. This form is not only an administrative requirement but a critical tool in monitoring the quality and effectiveness of care provided under the B2H program.

QuestionAnswer
Form NameForm Ocfs 8018
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOCFS 8018 Service Summary Form b2h medicaid payment wsp form

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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,):

DATE OF BIRTH:

SEX:

 

Male

Female

MEDICAID CIN #:

B2H WAIVER TYPE (Check one only)

B2H Serious Emotional Disturbance (SED) Waiver

B2H Developmental Disabilities (DD) Waiver B2H Medically Fragile (MedF) Waiver

DATE OF SERVICE:

START TIME:

AM PM

END TIME:

AM PM

TOTAL BILLABLE UNITS:

Service Location:

A. Waiver Services

 

B. Individual

C. Group

D Services Planning

E. Billable Unit

(Check ONE Service Only)

 

 

(Max Billing per 6 mos.)

 

Health Care Integration

 

 

 

 

Regular Full Month (Per one month)

 

 

 

 

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

OCFS-8018 (1/2012)

Description of service provided:

Description of child’s response to service. Include progress towards any identified goals or intervention strategies:

My signature verifies that the above service was provided.

HCI OR WSP NAME:

HCI OR WSP SIGNATURE:

 

DATE:

 

 

X

 

 

 

 

 

 

 

 

 

HCI SUPERVISOR OR WSP SUPERVISOR NAME:

HCI SUPERVISOR OR WSP SUPERVISOR SIGNATURE:

 

DATE:

 

 

X

 

 

 

 

 

 

 

 

 

HEALTH CARE INTEGRATION AGENCY(HCIA) / WSP AGENCY NAME:

PHONE #:

 

 

 

 

 

 

ADDRESS:

 

CITY:

STATE:

ZIP CODE:

 

 

 

 

 

 

NOTE: FOR HEALTH CARE INTEGRATION ONLY. SEE ACCOMPANYING PROGRESS NOTES DATED FOR THE FOLLOWING CONTACTS:

CONTACT WITH WAIVER SERVICE PROVIDERS IN THE INDIVIDUALIZED HEALTH PLAN (IHP)

Date

Date

CONTACT WITH CASE PLANNER/CASE MANAGER IF CHILD IS IN FOSTER CARE

Date

Date

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In an effort to complete this form, ensure that you provide the required information in each field:

1. Complete the Form Ocfs 8018 with a group of essential blank fields. Note all of the information you need and ensure there's nothing omitted!

Form Ocfs 8018 writing process clarified (step 1)

2. Once the last array of fields is done, it is time to put in the necessary specifics in FamilyCaregiver Supports Services, Day Habilitation, Special Needs Community Advocacy, Supported Employment, Planned Respite, Crisis Avoidance Management, Immediate Crisis Response Services, Intensive Inhome Supports Services, Hour, Hour, Hours, Hours, Hours, Hours, and Hour so you're able to move on further.

Find out how to fill in Form Ocfs 8018 portion 2

3. Completing Intensive Inhome Supports Services, Crisis Respite, Hours, Hour, Per min unit, Full day respite rate or more, hours, Using the chart above calculate, and SEE BH WAIVER RATE CODE MATRIX AND is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Hour, Hours, and Using the chart above calculate inside Form Ocfs 8018

4. The following subsection will require your details in the subsequent parts: OCFS Description of service, and Description of childs response to. It is important to provide all of the needed details to go forward.

Writing segment 4 of Form Ocfs 8018

5. The last section to submit this form is essential. Be sure to fill in the necessary blanks, including My signature verifies that the, CITY, DATE DATE, PHONE STATE, ZIP CODE, NOTE FOR HEALTH CARE INTEGRATION, CONTACT WITH WAIVER SERVICE, Date, CONTACT WITH CASE PLANNERCASE, and Date, before submitting. In any other case, it can result in an incomplete and probably incorrect form!

Form Ocfs 8018 completion process detailed (portion 5)

In terms of ZIP CODE and DATE DATE, make sure you don't make any mistakes in this section. These are certainly the key fields in the document.

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