When applying for HASA Admission Determination requiring Home Care Services, submit the M-11q.
Reason(s) for Referral: Services (Case Management), Benefits (PA/MA/FS), Housing or Other (check all that apply).
Household Composition: Individual (Adults only in H/H) or Family (Children Under Age 18 in H/H).
Medical Information: primary, secondary and additional diagnoses, each with a date of diagnosis, and TB Status.
Physician: Name (Print), Phone #, License # and Signature.
Social/Case Worker: Name (Print), Phone # and Agency or Institution.
| Question | Answer |
|---|---|
| Form Name | W-488X |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 47 |
| Avg. time to fill out | 8 min |
| Edition | Rev 01/08/2021 |
| Issuing agency | The City of New York Human Resources Administration |
| Other names | W-488X, W488X, 488X, HASA W-488X, HASA form, Request for Program Admission |
| Official source | W-488X (Rev 01/08/2021), City of New York Human Resources Administration |
W 488X Form isn’t the one you’re looking for?