DoH: Revised Effective Date: Updated Children’s HCBS Referral Form and Authorization Form with Instructional Guide

February 22, 2024

Children’s Waiver HCBS Providers, Medicaid Managed Care Plans (MMCPs) including Special Needs Plans, Health Homes Serving Children, Care Management Agencies (CMAs), and Child and Youth Evaluation Services (C-YES):

In response to stakeholder feedback, NYS DOH is revising the effective date of the updated Children’s HCBS Referral Form and Children’s HCBS Authorization and Care Manager Notification Form. The updated version of the Children’s HCBS Referral Form and Children’s HCBS Authorization and Care Manager Notification Form must be utilized for all new Referrals and Authorizations effective April 17th, 2024 by Children’s HCBS providers, MMCPs, HHSCs, CMAs, and C-YES. Use of previous versions of these forms is no longer permissible on or after this effective date. Earlier adoption of the these updated versions optional.

These forms as well as the associated Children’s HCBS Authorization and Care Manager Notification Instructional Guide can be found on the HCBS Plan of Care (POC) page of the DOH website:

Children’s HCBS Authorization and Care Manager Notification Form Instructional Guide – (PDF) – February 2024
Health Home Care Manager/C-YES Referral for Home and Community Based Services (HCBS) to HCBS Provider – (PDF) – Updated February 2024
Children’s HCBS Authorization and Care Manager Notification Form – (PDF) – Updated February 2024

Any questions or feedback on these documents can be sent to BH.Transition@health.ny.gov.