Referral Packet for Home and Community Based Services

Home and Community Based Care Provider Information

Home and Community Based Services Referral/Assessment Form
Home and Community Based Services Referral/Assessment Form (pdf format)
Home and Community Based Services Referral/Assessment Instructions

DA 3  Home and Community Based Services Care Plan Form
DA 3  Home and Community Based Services Care Plan Instructions

DA 3a Care Plan Supplement for In-Home Services Form 
DA 3a Care Plan Supplement for In-Home Services Instructions

DA 3c Care Plan Supplement for Consumer-Directed Services Form
DA 3c Care Plan Supplement for Consumer-Directed Services Instructions

Department of Health and Senior Services HIPAA Notice of Privacy Practices
Privacy Policies Acknowledgement Form 
Authorization for Disclosure of Consumer Medical/Health Information
Level of Care Policy

Referral for Other Services

If a referral is being made for other services only, such as HCB Medicaid, Respite Care, Home Delivered Meals, Independent Living Waiver, Adult Day Health Care, or the PACE Program, a Home and Community Based Services Referral Form (DA-1) should be completed and forwarded to the Central Registry Unit.  No additional paperwork is required.