Traumatic Brain Injury Program Manual
Forms
- Agreement Between the New York State Department of Health and a Provider of Home and Community-Based Waiver Services (PDF, 688KB, 4pg.)
- Application for Participation (PDF, 696KB, 1pg.)
- Freedom of Choice (PDF, 504KB, 1pg.)
- Service Coordinator Selection (PDF, 508KB, 1pg.)
- Regional Resource Development Specialist (RRDS) Approval of Final Cost (PDF, 524KB, 1pg.)
- Serious Reportable Incident Regional Resource Development Specialist (RRDS) Initial Response (PDF, 512KB, 1pg.)
- Serious Reportable Incident Regional Resource Development Specialist (RRDS) Status Report (PDF, 508KB, 1pg.)
- Notice of Decision Authorization (PDF, 464KB, 2pg.)
- Notice of Decision Denial of the Waiver Program (PDF, 588KB, 2pg.)
- Notice of Intent to Discontinue from the Waiver Program - B6.3 (PDF, 628KB, 3pg.)
- Notice of Intent to Discontinue from the Waiver Program - B6.4 (PDF, 624KB, 3pg.)
- Notice of Decision Denial of a Waiver Service (PDF, 592KB, 2pg.)
- Notification of Death of a Waiver Participant to Local Department of Social Services (PDF, 424KB, 1pg.)
- Home and Community Based Services Medicaid Waiver Service Provided Contact List (T) (PDF, 852KB, 2pg.)
- Environmental Modification (E-Mod) Description and Cost Projection (PDF, 508KB, 2pg.)
- Environmental Modification (E-Mod) Final Cost (PDF, 520KB, 1pg.)
- Assistive Technology Description and Cost Project (PDF, 528KB, 1pg.)
- Assistive Technology Final Cost (PDF, 520KB, 1pg.)
- Individual Service Report (ISR) (PDF, 724KB, 2pg.)
- Change of Provider Request (PDF, 512KB, 1pg.)
- Serious Reportable Incident Initial Provider Report (PDF, 508KB, 1pg.)
- Serious Reportable Incident 24-Hour Provider Report (PDF, 556KB, 3pg.)
- Serious Reportable Incident Follow-Up Provider Report (PDF, 508KB, 1pg.)