Ormation, see pages 8 & 9 of this form): Adding an additional HCBS waiver service: Individual is requesting to add a new HCBS waiver service. Do not use this form for service(s) previously authorized. Increasing service amount: Individual requesting an increase in service amount for an existing HCBS waiver service Changing provider: Individual is notifying DDRO of a change in provider INSTRUCTIONS: Please provide all information requested below. If you have any questions or need as.
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How to fill out the NY Service Amendment Request Form online
Completing the NY Service Amendment Request Form online is a straightforward process that allows individuals to request necessary amendments to their services. This guide provides clear instructions on how to fill out the form correctly and effectively.
Follow the steps to successfully complete your request.
- Press the ‘Get Form’ button to access and download the NY Service Amendment Request Form. Ensure it opens in your preferred document editor.
- Begin filling out the form by entering the individual's name, date of birth, and TABS ID number in the designated fields at the top of the form.
- Indicate the specific purpose of your request. Choose from options such as adding an additional HCBS waiver service, increasing service amounts, or changing providers. Make sure to check the box that corresponds to your request.
- Provide detailed contact information including the individual's county, address, Medicaid number, phone number, and email. Ensure that all information is accurate to avoid delays.
- List the current living situation and the primary contact person. Fill out any additional contact details for the primary contact as needed.
- Detail the care manager's information, including their name, title, and contact details. This section is essential for communication regarding the request.
- In the section regarding services currently received through OPWDD, clearly list all services along with the provider names and service amounts.
- Specify any non-OPWDD services and natural supports present in the individual's life, providing details and annual amounts where applicable.
- If the request involves dropping or reducing existing services, provide the necessary information about those services in the designated section.
- Complete the request fields for the specific services being requested, selecting the necessary options based on the type of service and desired outcomes.
- Once you have filled in all required information, review the document for accuracy and completeness. This step is crucial to avoid resubmission due to errors.
- Save your completed form on your device. You can then download, print, or share the document as needed before submitting it electronically.
Begin filling out your NY Service Amendment Request Form online today to ensure you receive the services you need!
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