Get Ny Doh Children And Family Treatment Supports Services Continuing Authorization Request Form

Filling out the NY DoH Children And Family Treatment Supports Services Continuing Authorization Request Form is an important step in requesting the continuation of services for children and families. This guide provides a clear and supportive overview of each section of the form to help users complete it accurately and effectively.

Follow the steps to successfully complete the authorization request form.

1. Click the ‘Get Form’ button to obtain the authorization request form and view it within your editing tool.
2. Begin by entering the member information in the designated fields. Include the member's name, date of birth, member ID, and whether they are enrolled in HCBS services. Also, provide guardian information, including their contact number and address, if applicable.
3. Fill out the health home and managed care plan information. If a health home care manager is applicable, include their name and contact details. Provide details about the managed care plan and the case manager, if known.
4. In the 'Children and Family Treatment Support Services Requested' section, select each service for which authorization is being requested. More than one service can be selected as needed.
5. Complete the CFTSS provider information section. Input the provider or agency name, tax ID, address, contact person, and their best contact time. Also include email addresses and contact numbers for the primary and an alternate contact.
6. Specify requested CFTSS information, including the start date for the first service visit, the frequency of services per week, intensity in hours per service, and the duration of services.
7. Clearly articulate the child’s goals for the service. List specific, measurable objectives that can be achieved within the requested period in the designated area.
8. Provide evidence for continued stay criteria. Describe the child’s involvement in reaching their service goals, document any progress made, and include input on family involvement.
9. Conclude with the provider attestation section by signing and dating the form. Ensure that the name and title of the person completing the form are printed clearly.
10. Once all fields are properly filled out, review the entire form for accuracy. After confirming that all information is correct, you may choose to save changes, download, print, or share the completed document as necessary.

Take the next step and complete the authorization request form online today.