Housing Stabilization Services (HSS) Referral Form Date: 2026

1. Click ‘Get Form’ to open the Housing Stabilization Services (HSS) Referral Form in the editor.
2. Begin by filling in the 'Referring County Staff' and 'Date' fields at the top of the form. Ensure accuracy as this information is crucial for processing.
3. Next, complete the 'Referring County', 'Phone', and 'Fax' sections. Include your NPI# for identification purposes.
4. In the 'Start Date' and 'End Date' fields, specify the relevant dates for service provision.
5. Fill out the personal details of the individual being referred, including their name, date of birth, sex, address, social security number, and contact information.
6. Indicate where the individual currently lives if different from their provided address. This helps in understanding their current situation.
7. Select applicable waiver types by checking 'Yes' or 'No' for each option listed under WAIVER TYPE.
8. Provide diagnosis codes related to housing stabilization services and any pertinent medical concerns in the designated sections.
9. Finally, review all entries for accuracy before saving or submitting your completed form through our platform.

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