Eligibility
Announcements
- Updated LPHA Guidance and Instructions - July 29, 2022
- LPHA Changes Announcement - December 2020 (PDF)
HCBS LPHA Attestation Forms
- 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)
Freedom of Choice Form
DOH-5276 - Freedom of Choice - Effective April 1, 2021
Medically Fragile Target Population Forms
- Disability Review Team Certificate - DOH 5144 (PDF)
- Childhood Medical Disability Report - DOH-5151 (PDF)
- Questionnaire of School Performance - DOH-5152 (PDF)
- Description of Child´s Activities - DOH-5153 (PDF)
- Disability Questionnaire - DOH-5139 (PDF)
- Authorization for Release of Health Information Pursuant to HIPAA - DOH 5173 (PDF)
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)
