Fillable TBI/NHTD Housing Subsidy Prior Approval Request HOME AND (New York State)

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TBI/NHTD Housing Subsidy Prior Approval Request HOME AND (New York State)

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TBI/NHTD Rev. March 2019 Page 1 of 1
TBI/NHTD Housing Subsidy Prior Approval Request
HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER
Nursing Home Transition and Diversion (NHTD)
Traumatic Brain Injury (TBI)
Name: _______________________________________ Date: ________
Current Address: Region: ________________________________
___ Transition ___ Diversion
Service Coordinator Name: _____________________________________
County participant is seeking to reside in: ______________________________
FMR: $_____________________ Number of Bedrooms: ___
Does the participant qualify for Community Transitional Services (CTS)? ____Yes ____No
Has housing been located? ____Yes ____No
If yes, what is the cost of rent per month? $________________
Anticipated move-in date: __________________
Will the participant require:
___ Broker’s Fees Anticipated Cost: $________ attach Broker’s Letter stating fees
___ Moving Expenses Anticipated Cost: $________
___ Household Goods Anticipated Cost: $________
___ Security Anticipated Cost: $________
___ Utility Anticipated Cost: $________
___ Deposit/Application Fee Anticipated Cost: $________
What other housing support resources have been explored or are being explored:
e.g. ___ Olmstead Outcome: _______________________________
___ Violent Crimes Outcome: _______________________________
___ Emergency Funds (LDSS) Outcome: _______________________________
Anticipated cost of request: $____________ Initial $____________ Monthly
Provide a brief justification for the request:
Approved ____ Yes ____ No
_________________________________________ __________
Maribeth Gnozzio, Division of Long Term Care Date
Attachment #2
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TBINHTD Housing Subsidy Prior Approval Request HOME AND (New York State)

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Completed 14 August 2020

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