DESCRIPTION AND COST PROJECTION FORM

Recipient Name: __________________________________________________________ Medicaid CIN: _________________

Request for: (Check One) ☐ AssistiveTechnology           ☐ Environmental Modification           ☐ Vehicle Modification

         ☐ Community Transitional Services (CFCO only)          ☐ Moving Assistance (CFCO only)

  1. Describe the service being requested.



  2. Explain how the service will contribute to the recipient´s health and welfare.



  3. Projected Cost $ Identify the selected bid.
    ☐ If the projected cost for the service will cause the aggregate calendar–year limit for that service to be exceeded, check here.
  4. Attach all evaluations and bids.


  5. For an E–Mod, if this is a rental property, a copy of the renter´s lease and signed permission from the landlord must be attached.

    ☐ For property that is owned by the individual or family, check box to indicate that proof of ownership was verified.
    ☐ For rented property, check box to indicate that the recipient attests that this is intended to be his/ her long–term, primary residence.

NEW YORK STATE DEPARTMENT OF HEALTH
Office of Health Insurance Program

Consent and Approval

Recipient Name: ______________________________________________________ Medicaid CIN: _____________________

Recipient Signature: ______________________________________________________ Date: ________________________

Legal Guardian/Representative (as applicable) Name: ______________________________________________________

Legal Guardian /Representative Signature: _________________________________ Date: ________________________

Home or Vehicle Owner Name: ______________________________________________________________________________

Home or Vehicle Owner Signature: __________________________________________ Date: ________________________

Service Provider Name: ___________________________________________________________________________________

Medicaid Provider ID# (as applicable): _____________________________________

Contact Name: ____________________________________________________

Contact Signature: __________________________________________________________ Date: ______________________

Care/Case Manager Name: ___________________________________________________

Care/Case Manager Signature: ______________________________________________ Date: ________________________

Modification/Purchase Approved:

Must submit a separate package for each modification/purchase.

☐ Assistive Technology                     ☐ Community Transitional Services

☐ Environmental Modification          ☐ Moving Assistance

☐ Vehicle Modification

LDSS Representative Name: ________________________________________________________________________________

LDSS Representative Signature: ____________________________________________ Date: ________________________

NEW YORK STATE DEPARTMENT OF HEALTH
Office of Health Insurance Program

Recipient Name: ________________________________________________Medicaid CIN: ____________________________

For LDSS only:

If you are requesting Special Project Voucher funding, please enter total project specific amount here and submit completed package to DOH through an option below.

Total Advance Requested $ ____________________

For DOH approval, please forward this form, its required documents and all supporting documentation from the checklist below:

  • ☐ Evidence of valid Recipient Restriction Exception (RR/E) codes from eMedNY, e.g., screenshot of the recipient´s eligibility file in eMedNY
  • ☐ Full Plan of Care (POC) or "Life Plan"
  • ☐ Physician´s order supporting the service request
  • ☐ Clinical justification provided by the appropriate clinician as per applicable service authorization guidelines

Fill out the following:

  • Have all other potential sources of payment been explored, including private insurance, community resources, and other State/federal programs? Yes No
  • Has recipient received/requested service before? Yes No

If yes, please provide details of service, i.e., when, where, why, final cost:



SUBMISSION – Securely submit this form and required supporting documentation via one of the secure methods below:

Mail Fax HCS
NYS DOH/OHIP
Division of Long Term Care
Attn: CFCO–Children´s Approval Unit
One Commerce Plaza, 16th Floor
99 Washington Avenue
Albany NY, 12210		 1–518–408–6045 CFCO–ChildrensApproval@health.ny.gov
For NYSDOH use only                                                                                      Tracking # ______________

Date Received: ______________ Date Reviewed: ______________ Reviewed By: ____________________________

For standard request: ☐ APPROVED           ☐ NOT APPROVED

For request to exceed calendar year limit:           ☐ APPROVED           ☐ NOT APPROVED

Date letter of support sent to LDSS: _______________

Rev. 6/2019