HSS Referral Form - Opportunity Community Services Inc. - wordpress-opportunitycommunityservices.com

Date of Referral

Referring Agency

NPI/UPMI

Name and Title

Phone

Email Address

Fax

Referral Request (Select One)

Initial Eligibility

Provider Change

Renewal Eligibility

Consultation

PCPlan Change

Additional Types of Request

Authorization Change from Transition to Sustaining

Authorization Change from Sustaining to Transition

Recipient Information

Name

First Last

Date Of Birth

Phone

PMI #

Social Security #

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient Status

Living Situation(Required)

Own Housing: Lease, Mortgage or Roommating

Service Provider: Foster Care, Group Home

Jail/Prison/Juvenile Detention

Emergency Shelter

Declined

Family/Friends Due to Economic Hardship

Hospital/Treatment/Detox/Nursing Home

Hotel/Motel

Place Not Meant For Housing

[ONE REQUIRED] Please provide essential details of current living situation and notes to best support the referral

Please provide essential details of current living situation and notes to best support the referral:

Housing Status:(Required)

Transitioning

Sustaining

Housing(Required)

Homeless

At-Risk For Homelessness

Transitioning From A Facility

Institutional Level of Care/Eligible For Waiver

Disability Type(Required)

SSI/SSDI Eligible

Injury or Illness with Extended Incapacitation

Developmental Disability

Mental Illness

Substance Use Disorder

Learning Disability

Consultation Status, if applicable

Agency Name

NPI

Name

First Last

Phone

Fax Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Eligibility Documents

Submit With Referral

Proof of Disability Type

Professional Statement of Need-PSN

State Medical Review Team (SMRT) Determination Letter

MA-DX/MA-BX

Social Security Award Statement (SSI/RSDI/SSDI)

Medical Opinion Form

Age 65-Years or Older

Only One Required

Proof of Disability Document

Max. file size: 40 MB.

Assessment Type

Professional Statement of Need-PSN (Non-Waiver)

Coordinated Entry Assessment

MnCHOICES ASSESSMENT (Waiver)

Long Term Care Consultation (LTCC)

Only One Required

Assessment Type Document

Max. file size: 40 MB.

Person Centered Plan Type

Housing-Focused Person Centered Plan (PCP) (Non-Waiver)

Coordinated Services and Supports Plan (CSSP) (Waiver)

Collaborative/Comprehensive Care Plan (CCP) (Elderly Waiver)

Only One Required

Person Centered Plan Type Document

Max. file size: 40 MB.

Additional Supporting Documents

FACESHEET

Optional, Yet Supportive

Additional Supporting Document Upload

Max. file size: 40 MB.

Housing Stabilization Services: Eligibility Request Initial or Renewal Form

NPI # A630005600

Recipient Information

Recipient Status

Consultation Status, if applicable

Eligibility Documents