Document Checklist

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