W 488X Form PDF Details

Navigating through the complexities of health and social services can be daunting, especially for those dealing with serious health conditions. One crucial step for individuals in New York City living with HIV/AIDS and in need of comprehensive support services is the submission of Form W-488X to the Human Resources Administration (HRA). This form, specifically designed for the HIV/AIDS Services Administration (HASA) program admission, serves as a gateway to a range of services aimed at improving the quality of life for people affected by HIV/AIDS. The form requires detailed information about the applicant's medical condition, including primary and any secondary diagnoses, as well as treatments and medications. Furthermore, it covers personal demographics, reasons for the referral to HASA—such as case management, benefits, housing needs—and details about the applicant's household composition. Proper completion of the W-488X form is a critical first step for individuals seeking specialized support, as it may also necessitate the submission of additional documents, like the M-11q form for those requiring home care services. By providing a structured process for program admission, this form not only facilitates access to essential services but also ensures that the specific needs of individuals with HIV/AIDS are adequately assessed and addressed by the City of New York.

QuestionAnswer
Form NameW 488X Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshasa application form, hasa program admission form, admission hasa program, hasa online

Form Preview Example

W-488X

THE CITY OF NEW YORK

HUMAN RESOURCES ADMINISTRATION

REV. 02/11

REQUEST FOR PROGRAM ADMISSION

When Applying for HASA Admission Determination submit HIV / AIDS Services Administration (HASA) Request for Program Admission form # W-488X.

When applying for HASA Admission Determination requiring Home Care Services submit the M-11q.

 

 

 

 

 

 

 

 

Social Security #

 

 

 

 

 

 

 

 

 

Patient Name (Print)

 

Sex

Race

 

Ethnicity

 

Date of Birth

 

 

 

 

 

 

 

 

Permanent Address No. and Street

 

Borough

 

 

Zip Code

 

Telephone #

1. Medical Information:

Primary Diagnosis (explain: e.g., HIV Positive, Symptomatic AIDS)

Secondary Diagnosis

Additional Diagnosis

TB Status:

No History

PPD+

History Treatment Complete

Active Non-Infectious

Date of Diagnosis

Date of Diagnosis

Date of Diagnosis

Directly Observed Therapy

2. Medication(s):

3. Reason(s) for Referral:

Services (Case Management)

Benefits (PA/MA/FS)

Housing

Other_____________

4.Household Composition: Individual (Adults only in H/H)

5.Physician:

Family (Children Under Age 18 in H/H)

Name (Print)

Phone #

License #

Signature

6. Social/Case Worker:

Name (Print)

Phone #

Agency or Institution

7. Request for Admission package completed:

Attached are completed form(s) {check all that apply}:

W-488X

M11q

How to Edit W 488X Form Online for Free

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Step 1: Firstly, access the tool by clicking the "Get Form Button" in the top section of this page.

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To be able to fill out this form, ensure that you provide the information you need in each and every blank:

1. Fill out your hasa documents with a number of necessary fields. Get all the important information and make certain there's nothing missed!

Part # 1 for completing hasa program admission form

2. Now that the previous segment is finished, you have to add the essential specifics in Services Case Management, Benefits PAMAFS, Housing, Other, Individual Adults only in HH, Family Children Under Age in HH, Name Print, Phone, License, Signature, Agency or Institution, Reasons for Referral Household, SocialCase Worker, Request for Admission package, and Name Print in order to go further.

Completing part 2 of hasa program admission form

It's simple to make a mistake while completing the Other, thus make sure you take a second look before you submit it.

Step 3: Ensure that the information is accurate and just click "Done" to continue further. Get hold of your hasa documents the instant you register here for a 7-day free trial. Readily view the form within your FormsPal account page, along with any modifications and adjustments being conveniently saved! Whenever you work with FormsPal, you can complete forms without worrying about information incidents or records being distributed. Our protected software ensures that your private information is stored safely.

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