Hcbs Form 02 02 97 – Fill Out and Use This PDF

The HCBS Form 02.02.97 is a crucial document developed by the State of New York Office for People with Developmental Disabilities for the purpose of determining eligibility for ICF/MR level of care. This form assesses various criteria including diagnosis, disability manifestation before age 22, health care needs, severe behavior problems, adaptive behavior deficits, and more to ensure individuals with developmental disabilities receive the appropriate level of support and care. Ready to secure the necessary care for yourself or a loved one? Click the button below to begin filling out the form.

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Hcbs Form 02 02 97 PDF Details

In the realm of providing care and support for individuals with developmental disabilities, the HCBS 02 02 97 form plays a crucial role as a standardized document within New York state. This form, also known as the ICF/MR-Level of Care Eligibility Determination (LCED) Form, serves as a comprehensive tool for evaluating an individual's eligibility for certain home and community-based services (HCBS). The Office for People With Developmental Disabilities (OPWDD) has put forth this document to ensure that individuals who require specialized attention and care can accurately be identified and provided with the appropriate services. By meticulously detailing the criteria for diagnosis, disability manifestation, health care needs, adaptive behavior deficits, and capacities in various areas such as communication, learning, mobility, independence, and self-direction, the form encapsulates the essential elements required for a thorough assessment. This form not only necessitates the collection of detailed information on an individual’s physical, social, and psychological evaluations but also involves a rigorous eligibility determination process, underscored by the requirement of signatures from qualified personnel, review physicians, and where relevant, the Director of the DDSO (Developmental Disabilities State Operations Office) or their designee. This multi-layered process emphasizes the form's significance in facilitating access to vital services while ensuring a tailor-made approach to each individual’s unique needs.

Question	Answer
Form Name	Hcbs Form 02 02 97
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	icf form 02 02 97, opwdd lced, level of care opwdd, opwdd fillable lced

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STATE OF NEW YORK

OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES

HCBS FORM 02.02.97 (5/2010, 4/2011)

FORM URAC-2 (4-86)

ICF/MR-LEVEL OF CARE ELIGIBILITY DETERMINATION (LCED) FORM

Please refer to the accompanying instructions for information on completing this form.

Name of Individual

Address

D.O.B.

Status:620 / 621

Responsible

Medicaid No (CIN)

TABS ID

Medicaid District

Dates of

Physical

Social

Psychological

Pre-enrollment Evaluations:

This information must be kept confidential by recipient

ELIGIBLITY DETERMINATION CRITERIA

1. DIAGNOSIS: A. Mental Retardation

C. Autism

E. Cerebral Palsy

G. Other

(specify:)

B. Epilepsy

D. Neurological impairment

F. Familial Dysautonomia

2. DISABILITY MANIFESTED PRIOR TO AGE 22:

YES NO

4. HEALTH CARE NEED: YES NO

3. SEVERE BEHAVIOR PROBLEM: YES	NO
A. Daily B. Weekly C. Monthly	D
A. Daily B. Weekly C. Monthly	. Occurred in past 12 months

A. Individual has a medical condition which requires daily individualized attention from health care staff						YES	NO

B. Individual displays self-injurious behavior which necessitates monitoring and treatment						YES	NO

C. Individual has deficits in self-care skills						YES	NO

1.	Extremely limited self-help skills, requires total assistance with self-care tasks					YES	NO

2.	Demonstrates some self-help skills, but requires assistance and training in performing self-care tasks					YES	NO

5. ADAPTIVE BEHAVIOR DEFICIT: YES				NO
A. COMMUNICATION: YES			NO

1.	Individual has extremely limited expressive or receptive language skills					YES	NO

2.	Individual has some expressive or receptive language but requires assistance to communicate needs					YES	NO

B. LEARNING: YES		NO

1.	I.Q. score cannot be determined using standardized test measures (certified untestable)					YES	NO

2.	I.Q. score of less than 50					YES	NO

3.	Over 21 years of age, person’s reading and computation skills are at first grade level or below					YES	NO

4.	I.Q. score of 50 – 69					YES	NO

5.	Over 21 years of age, person’s reading and computational skills are at third grade level or below					YES	NO

C. MOBILITY: YES		NO

1.	Individual is non-ambulatory and totally dependent on staff for moving from one place to another					YES	NO

2.	Individual has some mobility skills but needs staff assistance and training to increase his/her capacity for moving about					YES	NO

D. CAPACITY FOR INDEPENDENT LIVING: YES					NO

1.	Individual is completely dependent on others for all household activities					YES	NO

2.	Individual needs assistance or training to perform tasks to be a contributing member of household					YES	NO

E. SELF-DIRECTION: YES			NO

1.	Individual exhibits frequent (i.e., weekly) challenging behaviors requiring individualized programming					YES	NO

2.	Individual is completely dependent on others for management of his/her personal affairs within the general community					YES	NO

3.	Individual exhibits episodic (i.e., monthly) challenging behaviors requiring individualized programming					YES	NO

4.	Individual needs assistance or training for management of his/her personal affairs within the general community					YES	NO

					See next page for required signatures.
ICF/MR LCED Form						Page 1 of 2

Made fill-able 5/11

STATE OF NEW YORK

OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES

HCBS FORM 02.02.97 (5/2010, 4/2011)

FORM URAC-2 (4-86)

Name of Individual:

Signature of Qualified Person Completing the Form Signature of Review Physician

Medicaid No (CIN):

Review

Date

Review

Date

This section to be completed by the DDSO Director (or Designee) for initial LCED determinations only

Has the OPWDD process for DD Eligibility been completed by the DDSO?	YES	NO

ICF/MR Level of Care Approved Effective (mm/dd/yy):	ICF/MR Level of Care NOT Approved

Date of Waiver Enrollment (mm/dd/yy):

Signature of DDSO Director (or Designee):

Date (mm/dd/yy):

Annual ICF/MR Level of Care Eligibility (LCED) Redetermination

The annual LCED redetermination must be reviewed within 365 days from the last review date or the effective date in the field “ICF/MR Level of Care Approved Effective (mm/dd/yy)” above.

By signing below, I affirm that based upon my knowledge of the individual and a review of the most recent psychological evaluation, social evaluation/history, medical history, and the information outlined in questions 1-5, that there has been no significant change that impacts this individual’s eligibility for ICR/MR level of care. The LCED is redetermined to be effective for one year (i.e., 365 days) from the signature date below.

Signature and Title of Qualified Person Completing the Form

Review Date

Note: If an individual no longer meets the ICF/MR level of care, the DDSO must immediately be contacted for further action.

ICF/MR LCED Form

Page 2 of 2

Made fill-able 5/11

How to Edit Hcbs Form 02 02 97 Online for Free

With the help of the online editor for PDFs by FormsPal, you'll be able to fill in or modify icf form 02 02 97 here and now. To keep our editor on the leading edge of efficiency, we strive to integrate user-driven capabilities and enhancements on a regular basis. We're routinely looking for feedback - assist us with reshaping the way you work with PDF docs. To begin your journey, consider these easy steps:

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With regards to the blanks of this specific PDF, here's what you need to know:

1. The icf form 02 02 97 needs particular details to be entered. Ensure the next fields are filled out:

opwdd lced forms completion process outlined (portion 1)

2. Soon after completing the last section, go on to the next part and enter all required particulars in all these fields - Demonstrates some selfhelp skills, ADAPTIVE BEHAVIOR DEFICIT YES, A COMMUNICATION YES, Individual has extremely limited, Individual has some expressive or, B LEARNING YES, IQ score cannot be determined, IQ score of less than, Over years of age persons, IQ score of, Over years of age persons, C MOBILITY YES, Individual is nonambulatory and, YES, and YES.

Individual has extremely limited, IQ score of less than, and IQ score cannot be determined inside opwdd lced forms

3. Your next part is usually straightforward - fill in every one of the fields in E SELFDIRECTION YES, Individual exhibits frequent ie, YES, Individual is completely, Individual exhibits episodic ie, Individual needs assistance or, YES, YES, ICFMR LCED Form, Page of, Made fillable, and See next page for required to conclude this part.

The right way to complete opwdd lced forms stage 3

As for YES and Individual is completely, be sure that you take another look in this section. Those two are definitely the most significant fields in this form.

4. All set to start working on this next portion! Here you've got all these Name of Individual, Medicaid No CIN, Signature of Qualified Person, Signature of Review Physician, Review Date Review Date, This section to be completed by, Has the OPWDD process for DD, YES, ICFMR Level of Care Approved, ICFMR Level of Care NOT Approved, Date of Waiver Enrollment mmddyy, Signature of DDSO Director or, Date mmddyy, Annual ICFMR Level of Care, and The annual LCED redetermination blanks to fill in.

Signature of Qualified Person, ICFMR Level of Care Approved, and Signature of DDSO Director or in opwdd lced forms

5. This form should be wrapped up with this particular segment. Here you can see an extensive list of form fields that require appropriate information for your document submission to be faultless: Signature and Title of Qualified, Review Date, Note If an individual no longer, ICFMR LCED Form, and Page of.

Step 3: Soon after going through the form fields you've filled in, click "Done" and you are done and dusted! Sign up with us today and easily use icf form 02 02 97, available for downloading. Every single edit you make is handily saved , allowing you to modify the document at a later time when necessary. We don't share or sell the information you use while dealing with forms at our website.

Hcbs Form 02 02 97 – Fill Out and Use This PDF

Hcbs Form 02 02 97 PDF Details

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