Ny hcf form 2025

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4.8 out of 5

71 votes

The document is a referral form for the Department of Homeless Services (DHS) in New York City, designed for healthcare facilities to refer single adult patients to DHS shelters or Safe Haven facilities. It outlines the criteria for medical appropriateness, necessary information for completion, and procedures for submitting the form. The form emphasizes that patients must be independent in daily activities and details exclusion criteria based on health conditions. It also includes sections for patient demographics, clinical information, functional status, medication lists, discharge plans, and treatment team approval.

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Click ‘Get Form’ to open the ny hcf form in the editor.
Begin by entering the Client Name (First, Last) and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
In Section 1, provide detailed healthcare facility information including the facility name, contact details, and primary care physician's information.
Complete Section 2 regarding placement efforts for new clients. Document all attempts made to secure non-shelter housing options before referral.
Fill out Section 3 with clinical information, detailing the reason for admission and any relevant medical history that may affect shelter placement.
Review all sections for completeness. If any required fields are missing, our platform will prompt you to fill them in before submission.
Once completed, email the form to the appropriate DHS address provided in the instructions. Ensure you receive a confirmation of receipt.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (71 Votes)
2018	4.4 Satisfied (57 Votes)

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