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New York State Department of HealthHealth Home Care Management/YES Referral for Home and Community Based Services (HUBS) to HUBS Provider Medicaid 1915© Children's Waiver Program SECTION I: To be
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Obtain a blank copy of the hcbs-referral-formpdf.
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Fill out all required information accurately, including personal information, contact details, and medical history.
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Provide any additional documentation or information required to support the referral.
04
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Who needs hcbs-referral-formpdf?

01
Individuals who are seeking Home and Community Based Services (HCBS) may need to fill out the hcbs-referral-formpdf.
02
Caregivers or family members of individuals in need of HCBS may also need to complete this form on behalf of the recipient.
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The HCBS Referral Form PDF is a document used to refer individuals for Home and Community-Based Services (HCBS), which supports people in receiving care in their homes or communities rather than in institutional settings.
The HCBS Referral Form PDF must be filed by health care providers, case managers, or agencies involved in coordinating care for individuals seeking HCBS.
To fill out the HCBS Referral Form PDF, gather the necessary information about the individual being referred, complete all required sections on the form, including personal details, medical history, and the specific services needed, and then submit it to the appropriate agency.
The purpose of the HCBS Referral Form PDF is to initiate the assessment process for individuals who require home and community-based services and to ensure they receive appropriate support and services.
The HCBS Referral Form PDF must report personal identification information, medical history, current health conditions, required services, and any additional relevant information that supports the referral.
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