HCBS Referral Application

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

YesNo

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?*

NoYes
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?*

Day HabilitationRespiteCommunity HabilitationSupported EmploymentNoN/A
Is the applicant already receiving any of these services from another agency?*

YesNo
Agency Name *
Respite Services desired?*

Respite (DPP)Respite (ASSD)Not desired
Number of annual respite service hours desired?*
Comm Hab Services desired?*

Comm Hab (DPP)Comm Hab (ASSD)Not 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?*

YesNo
If yes to allergies, please describe:
Does the applicant have seizures?*

YesNo
If yes to seizures, please describe:
Does the applicant have any need for meal time support?*

YesNo
If yes to need meal time supports, please describe:
Does the applicant have any behavioral support needs?*

YesNo
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.*

YesNo
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.*

YesNo
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?*

YesNo
Does the applicant have access to internet service including WiFi capability?*

YesNo
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