Eligibility
Announcements
- LPHA Changes Announcement - December 2020 (PDF)
HCBS LPHA Attestation Forms
- Serious Emotional Disturbance (SED) LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
- Medically Fragile (MF) LPHA Attestation (DOH Form - 5275) - updated December 2020 (PDF)
- Developmental Disabled who are Medically Fragile (DDMF) 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)
Freedom of Choice Form
DOH-5276 - Freedom of Choice - Effective April 1, 2021
Medically Fragile Target Population Forms
Notice of Decision Forms
DOH-5287 Form
Notice of Decision For Enrollment or Denial of Enrollment in the New York State 1915(c) Children´s Waiver - Updated April 1, 2021
DOH-5288 Form
Notice of Decision For Discontinuance in the New York State 1915(c) Children´s Waiver - Updated April 1, 2021
Participant Rights and Responsibilities Fact Sheet
- English - (PDF)
- Bengali - (PDF)
- 中文 (Chinese) - (PDF)
- Kreyòl Ayisyen (Haitian-Creole) - (PDF)
- 한국어 (Korean) - (PDF)
- Русский (Russian) - (PDF)
- Español (Spanish) - (PDF)
