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Get NY OCFS-8017 2012-2024

To be completed by Health Care Integrator (HCI). NAME OF HEALTH CARE INTEGRATION AGENCY (HCIA): REFERRAL SOURCE: Local Department of Social Services (LDSS) Division of Juvenile Justice and Opportunities for Youth (DJJOY) CHILD’S NAME (LAST, FIRST, MI,): DATE OF BIRTH: SEX: MEDICAID CIN #: Male Female B2H WAIVER TYPE (Check one only) IHP DEVELOPMENT Attach minutes of Team Meetings convened to develop this IHP. Minutes must include individuals who participated and the date of meeting(s.

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