Follow the steps to effectively fill out the form online.

1. Click ‘Get Form’ button to obtain the form and access it in your preferred editing tool.
2. Begin by entering the date of referral in the designated space. Ensure that the format follows MM/DD/YYYY and includes any additional required notes such as referral number and region.
3. Provide the applicant's name, selecting the appropriate title (Mr., Mrs., Ms.) and filling out the first name, middle initial, last name, and any generational suffixes.
4. Fill in the dates for when you were contacted, the date the intake is scheduled, and the final intake date, using the same MM/DD/YYYY format.
5. For applicant information, select the current location from the options provided, such as private residence or nursing home, and fill out the location address, including street, city, state, and zip code.
6. Indicate whether the applicant has legal guardianship and, if applicable, provide the legal guardian's name and contact details. Include the relationship of the contact person to the applicant.
7. In the demographics section, enter the applicant's birth date, select their sex, and indicate their marital status.
8. Document the applicant’s race/ethnicity by selecting one from the provided options.
9. Indicate the Medicaid status of the applicant, providing additional information regarding Medicare status as necessary. Include details about any insurance plans.
10. In the diagnosis/needs section, report any primary and other diagnoses while describing the physical, cognitive, and behavioral concerns detailed for the applicant.
11. Specify the support the applicant requires, distinguishing between informal and formal help, and include any previous experience with New York State HCBS waivers.
12. Conclude by noting the proposed living arrangements and awaiting decisions by completing the intake status and any relevant comments.
13. Once all fields are accurately filled, save any changes, then download, print, or share the form as needed.

Begin your document filing process online today to ensure your submissions are handled efficiently.