HCBS Referral Application

HCBS Referral Application
Has a staff person been identified to provide this service?

Application Date

MonthDayYear
Date
Individual's Name

First NameLast Name
Individual's Date of Birth

MonthDayYear
Date
Individual's Medicaid #
Ex. AB12345C
TABS ID
Primary ICD-10 Diagnosis Code
Primary Contact Phone

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
School Age?
School District Name
Designee/Advocate

First NameLast Name
Designee/Advocate Primary Phone

Area CodePhone Number
Designee/Advocate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Designee/Advocate Email
example@example.com
Designee/Advocate Relationship to the Individual
Program Questions
Is the applicant receiving other Springbrook services?
Is the applicant already receiving any of these services from another agency?
Agency Name
Respite Services desired?
Number of annual respite service hours desired?
Comm Hab Services desired?
Number of annual comm hab service hours desired?
Indicate the time range on the days the individual is interested in utilizing the service(s).

For example, on Tuesday type 9-11 a.m. This will indicate the day of the week and the time frame the individual would like.
Monday
Indicate the time range for Monday (include a.m. or p.m.)
Tuesday
Indicate the time range for Tuesday (include a.m. or p.m.)
Wednesday
Indicate the time range for Wednesday (include a.m. or p.m.)
Thursday
Indicate the time range for Thursday (include a.m. or p.m.)
Friday
Indicate the time range for Friday (include a.m. or p.m.)
Saturday
Indicate the time range for Saturday (include a.m. or p.m.)
Sunday
Indicate the time range for Sunday (include a.m. or p.m.)
Valued Outcomes/Possible Goals Related to Service (for Comm Hab only). Please number each goal and place on a new line:
Name of staff

First NameLast Name
Staff's email address
example@example.com
Staff phone number

Area CodePhone Number
Does the applicant have allergies?
If yes to allergies, please describe:
Does the applicant have seizures?
If yes to seizures, please describe:
Does the applicant have any need for meal time support?
If yes to need meal time supports, please describe:
Does the applicant have any behavioral support needs?
If yes, please upload behavior support plans here.

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Is the applicant approved for physical interventions, such as SCIP-R? OPWDD Community Habilitation and Respite staff are not able to perform physical interventions, such as SCIP-R.
Does the applicant need assistance with medical procedures during service delivery? OPWDD Community Habilitation and Respite are not able to provide support with medical procedures.
If yes to need assistance with medical procedures, please describe:
What are the applicant's likes and interests
What are the applicant's dislikes and fears
Does the applicant have a working laptop, tablet, or other smart technology device?
Does the applicant have access to internet service including WiFi capability?
If the applicant does not have access to a device or internet services, what alternatives could be explored?
Please upload the Life Plan, including all attachments here.

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Notes from the CCM:
Name of CCM submitting application

First NameLast Name
Care Coordination Agency
Email address of CCM submitting application
example@example.com
Phone Number of CCM submitting application

Area CodePhone Number
*Attention CCM: CCM will not list Springbrook as the service provider on any of the individual’s documents until the CCM receives this signed/approved HCBS Referral Form back from Springbrook.

HCBS Sender Email
example@example.com
Should be Empty:

HCBS Referral Application

Program Questions