Document Checklist

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checkbox Psychological Evaluation (with Full Scale IQ, Adaptive Testing, Autism specialty reports, IEPs or any applicable evaluations) – completed within the last three years
checkbox Psychosocial Evaluation (with developmental milestones) – completed within the last year
checkbox Medical Evaluation (signed by a physician) – completed within the last year
checkbox OPWDD Eligibility Letter – Current Level of Care Eligibility Determination (LCED)
checkbox Signed Consent Form – original/electronic signature needed
checkbox DOH 5055 Adult Consent Form
checkbox DOH 5200 (Under 18) Consent Form
checkbox DOH 5201 (Under 18) Consent Form
checkbox ROA – Receipt of Acknowledgment
checkbox HIPAA Release of Information – Authorization for Release of Protected Health Information
checkbox State Paid Care Management Consent Form