Get B-1.5 Provider Selection Form - New York State Department Of Health - Health Ny

The B-1.5 Provider Selection Form is essential for participants in the Traumatic Brain Injury Medicaid waiver to select their approved service providers. This guide will walk you through the steps to fill out the form online, ensuring a smooth process for your provider selection.

Follow the steps to complete the B-1.5 Provider Selection Form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the B-1.5 Provider Selection Form and open it in your preferred editing tool.
2. Carefully read the instructions provided at the beginning of the form to ensure you understand the process and requirements for provider selection.
3. From the list of approved Waiver Service Provider Agencies, select your chosen Provider Agency and write their name in the designated field.
4. Enter the telephone number and address of the selected Provider Agency in the respective fields to ensure accurate contact information.
5. List the specific services you are requesting from the selected Provider Agency in the spaces provided. Be precise and refer to the approved services if needed.
6. Sign and date the applicant's signature section, confirming your selection and understanding of the process.
7. If applicable, have a legal guardian or authorized representative sign and date their respective sections to validate the form.
8. For the Provider Agency section, ensure that the selected provider confirms their ability to deliver the requested services by providing their signature and date.
9. Finally, save the completed form, download it for your records, and share it with your Service Coordinator as instructed.

Complete your B-1.5 Provider Selection Form online today to begin the provider selection process.