Recipient Name: __________________________________________________________ Medicaid CIN: _________________

Final cost for: (Check One)      AssistiveTechnology           Environmental Modification           Vehicle Modification

          Community Transitional Services (CFCO only)           Moving Assistance (CFCO only)

  1. Original Projected Cost: $ __________________           Final Cost: $ __________________
  2. Justify any difference of more than 10% of the above original cost.

  3. Describe the completed Service. Attach itemized list of all expenses incurred along with copies of all receipts.

Provider Certification

I certify that the above Service was provided in accordance with the above costs.

Service Provider /Agency: ________________________________________________ Provider Medicaid #: ____________________

Provider Address: ______________________________________________________ Telephone: ___________________________

Provider Contact Name: _____________________________________________________________________________________

Provider Contact Signature: ____________________________________________________________ Date: _________________

Care/Case Manager Certification

I acknowledge that the above service was provided in accordance with the Person Centered Plan of Care.

Care/case manager Name: __________________________________________________________________________________

Care/case manager Name Signature: _____________________________________________________ Date: _________________

Local Department of Social Services (LDSS) or Developmental Disabilities Regional Office (DDRO) Approval

LDSS or DDRO Signature: __________________________________________________________________ Date: ________________

          Print Name: ___________________________________________

Submit to DOH using one of the secure options below:

Mail Fax HCS
Division of Long Term Care
Attn: CFCO–Children´s Approval Unit
One Commerce Plaza, 16th Floor
99 Washington Avenue
Albany NY, 12210
1–518–408–6045 CFCO–
(Rev. 6/2019)