HCBS Request for Services Form : Services : Abbott House

HCBS Request for Services Form

Today's Date

Month

Day

Year

Level of Care Date

Month

Day

Year

Child's Name

First Name *

Middle

Last Name *

Capacity Management Approval Slot Date

Month

Day

Year

Date of Birth (Required)

Medicaid/CIN # (Required)

Personal Making Referral

First Name *

Last Name *

Contact Number (Required)

Referring Agency Name

Contact Number

Care Coordinator Name:

First Name

Last Name

Contact Number

Case Planner Name

First Name

Last Name

Contact Number

Manage Care Company Name (Required)

Contact Number: (Required)

Member ID# (Required)

Basic Demographics

Child's Current Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Gender

Male
Female
Not Known

School Name: (Required)

School Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

If other please specify below

School Contact Name/Title

First Name

Middle

Last Name

School Contact Number: (Required)

Caregiver Information:

Name

First Name *

Last Name *

Primary Contact Number: (Required)

Second Contact Number:

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

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Presenting Behaviors (Please Explain) (Required)

HCBS Service Request

*Please Note

Child must be Medicaid-eligible
Access is through Children's Health Home (HH) or State-Designated Independent Entity C-YES
HH Care Manager or C-YES will complete HCBS Level of Care Eligibility Determination

Community Habilitation
Caregiver/Family Supports and Services
Respite
Prevocational Services
Supported Employment
Community Self-Advocacy Training and Supports

Supporting Documentation

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