OCFS-8018 (1/2012) NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES SERVICE SUMMARY FORM BRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM INSTRUCTION: To be.
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How to fill out the B2h Medicaid Payment Wsp Form online
Filling out the B2h Medicaid Payment Wsp Form online can seem daunting, but with clear guidance, you can complete it accurately. This form is essential for documenting services provided under the Bridges to Health Medicaid Waiver Program.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin by entering the child's name in the designated fields, including last name, first name, and middle initial.
- Indicate the child's sex by selecting either 'Male' or 'Female'.
- Provide the child's date of birth in the specified format.
- Input the Medicaid Client Identification Number (CIN) in the appropriate section.
- Select the B2H waiver type by checking one of the options provided: Serious Emotional Disturbance (SED), Developmental Disabilities (DD), or Medically Fragile (MedF).
- Fill in the date of service along with the start time and end time, distinguishing between AM and PM where required.
- Calculate and enter the total billable units based on the provided service times, ensuring accuracy.
- Choose the service location and indicate whether the service is in-home or another location.
- Select the specific service provided, checking the relevant box under either Waiver Services, Individual, or Group options.
- Using the chart provided, calculate and fill in the Total Billable Units according to the service type as described.
- Provide a brief description of the service provided and the child’s response, including any progress toward identified goals.
- Sign and date the form in the designated area for the Health Care Integrator (HCI) or Waiver Service Provider (WSP).
- If applicable, have the HCI supervisor or WSP supervisor sign and date the form as well.
- Finally, review all entered information for accuracy before saving, downloading, printing, or sharing the completed form.
Start filling out the B2h Medicaid Payment Wsp Form online to ensure timely processing of services.
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