Provider Attestation

Member info

Eligibility criteria

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Member information

First name

Last name

Date of birth *

Medicaid ID (CIN) optional

Check all criteria that apply to this member

Behavioral & Developmental Health Needs

Substance Use Disorder (SUD)

Diagnosed with SUD (alcohol, opioids, marijuana, heroin, etc.) interfering with daily life, physical health, or involving illegal substance use.

Severe Mental Illness (SMI)

Persistent or life-threatening mental health condition requiring stabilization — e.g., schizophrenia, bipolar disorder, or at risk of suicide.

Intellectual or Developmental Disability (I/DD)

Requires services/supports to achieve care goals — e.g., Autism, Cerebral Palsy, Epilepsy, Prader-Willi syndrome, Fetal Alcohol Syndrome.

Maternal & Child Health

Pregnant or up to 12 months postpartum

Currently pregnant or within 12 months of delivery, miscarriage, or termination.

Pregnant / postpartum — requires refrigerated breast milk

Same postpartum window as above with documented need for breast milk refrigeration.

High-risk child under 18

CYSHCN status, low birth weight (<2500g), documented chronic condition, or history of maltreatment.

Child under 18 — obese, underweight, or malnourished

Child at risk of developmental/growth delay due to malnutrition, overweight, underweight, or obesity.

Special Medical Care — Adults (Medical Respite)

Pre-procedure requirement

Member requires care or support in preparation for a scheduled procedure.

Post-hospitalization care

At risk for inpatient/ED hospitalization AND needs recuperation; OR transitioning from institution or acute care related to a health condition.

Nutritional & Home Modification Needs

Enteral or parenteral nutritional therapy

Member is receiving tube feeding or IV nutrition.

Medically necessary home modifications

Physical disability requiring modifications for safety/access — e.g., ramps, handrails, grab bars.

Condition exacerbated by home environment

Condition worsened by moisture, mold, pests, or indoor air quality — e.g., asthma, COPD, environmental allergies, atopic dermatitis.

Medical necessity for home remediation

Documented need for mold or pest remediation in the home.

Environmental & Temperature-Related

Condition affecting thermoregulation

Medical condition or medications that significantly impair temperature regulation, including dependence on others for environmental control.

Heat-related illness — ER or urgent care (last 12 months)

Visited ER or urgent care for a heat-related illness within the past year.

Cold-related illness — ER or urgent care (last 12 months)

Visited ER or urgent care for a cold-related illness within the past year.

Chronic Health Conditions

Chronic condition (DOH-listed)

Pre-diabetes, diabetes, chronic Hepatitis-C, CHF, chronic kidney disease, COPD, obesity, hypertension, malignancies, asthma, sickle cell, HIV/AIDS, Alzheimer's, arthritis, and others on the DOH list.

Requires refrigerated medications for chronic condition

Chronic condition management depends on refrigerated medications — e.g., certain insulins, biologics.

Asthma

1+ inpatient hospital stay for asthma (last 12 months)

At least one asthma-related hospital admission in the past year.

2+ ED visits for asthma (last 12 months)

Two or more emergency department visits related to asthma in the past year.

2+ urgent care visits for asthma (last 12 months)

Two or more urgent care visits related to asthma in the past year.

2+ oral steroid prescriptions for asthma (last 12 months)

Two or more prescribing events for oral steroids related to asthma diagnosis in the past year.

3–11 rescue inhaler prescriptions (last 12 months)

Between 3 and 11 prescribing events for a rescue inhaler including albuterol — indicating frequent acute need.

Other

Medicaid high utilizer

5+ ED visits in last 12 months; OR 4+ ED visits AND 1+ inpatient stays; OR 2+ inpatient stays in last 12 months.

Enrolled in NYS Health Home

Currently enrolled in a New York State Health Home care management program.

Homeless

Literally homeless, facing imminent homelessness, homeless under federal regulations, or fleeing domestic violence. Per HUD definition (24 CFR 91.5).

Transitioning out of institutional / congregate care (last 90 days)

Discharged within 90 days from a nursing facility, group home, correctional facility, State Psychiatric, SRO, or acute care hospital.

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Esther Sobel

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Osnat Cohen

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Jennifer Kahan

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Attestation

"I hereby attest that the information contained herein is current, complete, and accurate to the best of my knowledge and belief. I understand that my attestation may result in the provision of services which are paid for by state and federal funds and I also understand that whoever knowingly and willfully makes or causes to be made a false statement, or representation may be prosecuted under the applicable federal and state laws."

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Date

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Attestation submitted

The provider attestation has been recorded in Jotform successfully.