Eligibility

  • Serious Emotional Disturbance (SED) LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
    • Instructions to Complete the LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
    • Guide to Edits to the LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)

Archived

  • ARCHIVED: Medically Fragile (MF) LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
  • ARCHIVED: Developmental Disabled who are Medically Fragile (DDMF) LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
DOH-5276 - Freedom of Choice - Effective April 1, 2021

Notice of Decision For Enrollment or Denial of Enrollment in the New York State 1915(c) Children´s Waiver - Updated April 1, 2021

Notice of Decision For Discontinuance in the New York State 1915(c) Children´s Waiver - Updated April 1, 2021