Services Housing Stabilization Services: Eligibility Request Initial or Renewal Form NPI # A630005600 HSS Home Date of Referral Referring Agency NPI/UPMI Name and Title Phone Number Email Address Fax Referral Request (Select One) Initial EligibilityProvider ChangeRenewal EligibilityConsultationPCPlan Change Additional Types of Request Authorization Change from Transition to SustainingAuthorization Change from Sustaining to Transition Recipient Information First Name Last Name Date of Birth Phone Email PMI # Social Security # Mailing Address Street Address# Address Line 2 City State/Province/Region Zip/Postal Code Country Recipient Status Living Situation Own Housing: Lease, Mortgage or RoommatingService Provider: Foster Care, Group HomeJail/Prison/Juvenile DetentionEmergency ShelterDeclinedFamily/Friends Due to Economic HardshipHospital/Treatment/Detox/Nursing HomeHotel/MotelPlace 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 TransitioningSustaining Housing HomelessAt-Risk For HomelessnessTransitioning From A FacilityInstitutional Level of Care/Eligible For Waiver Housing Type SSI/SSDI EligibleInjury or Illness with Extended IncapacitationDevelopmental DisabilityMental IllnessSubstance Use DisorderLearning Disability Consultation Status, If Applicable Agency Name NPI First Name Last Name Phone Email Fax Number Mailing 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-PSNState Medical Review Team (SMRT) Determination LetterMA-DX/MA-BXSocial Security Award Statement (SSI/RSDI/SSDI)Medical Opinion FormAge 65-Years or Older Proof Of Disability Document Max. file size: 40 MB Assessment Type Professional Statement of Need-PSN (Non-Waiver)Coordinated Entry AssessmentMnCHOICES ASSESSMENT (Waiver)Long Term Care Consultation (LTCC) 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) Person Centered Type Plan Document Max. file size: 40 MB Additional Supporting Document Facesheet Additional Supporting Document Upload (Optional) Max. file size: 40 MB
