New York State Department of Health 1915(c) Children’s Waiver Participant/Parent/Caregiver Agreement - Instructions, Section I and Section II

Sep 16, 2026

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New York State Department of Health 1915(c) Children’s Waiver agreement for participants, parents, and caregivers covering Environmental Modification (EMod), Vehicle Modification (VMod), and Adaptive and Assistive Technology (AAT). The form requires review of the project scope, confirmation of receipt of the information sheet, and acknowledgment of restrictions on making changes or contacting contractors directly. It also sets responsibilities for maintenance, approved upgrades, insurance coverage, potential project stopping conditions, and limits on responsibility for removal or damage. Section II applies only when revising project scope.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

SECTION I

Project type and participant acknowledgment

Signatures and dates

SECTION II – For Change in Project Scope Only

Revised scope acknowledgment

NEW YORK STATE DEPARTMENT OF HEALTH 1915(c) Children’s Waiver Bureau of Specialized Services for Children Participant/Parent/Caregiver Agreement Children’s Waiver Participant/Parent/Caregiver Agreement for Environmental Modification (EMod), Vehicle Modification (VMod), and Adaptive and Assistive Technology (AAT) Instructions: Review the following information and ensure that you as the waiver participant/parent/caregiver agree with all items below by initialing each item and signing at the end of Section I to show agreement. Complete Section II only when a change in project scope is needed after Section I has already been completed and signed. SECTION I Participant’s Name: DOB: CIN\# Project type (check one): EMod Vmod AAT Project number I agree to receive the proposed , as (Bathroom, Ramp, Vehicle chair tie down, etc.) outlined in the provided written evaluation, dated ( / / ), attached to this agreement. I have received and read a copy of the Participant/Parent/Caregiver Information Sheet on EMods, VMods, or AAT. I agree to maintain the existing state of the vehicle or the area of the structure to be modified and will not make any changes that would impact the project, after agreeing to the provided project scope. I understand that I am not permitted or authorized to make changes or address project issues directly with the contractor/provider. If any changes are needed, I will notify my care manager, and/or Financial Management Service (FMS) provider, prior to starting any changes to the structure/vehicle. I understand that I am allowed to request one revision of the EMod/VMod or AAT scope. If I request more than one revision, additional revisions will not be considered, and the project may be subject to denial and closure. I understand that I am responsible for the maintenance of and repairs to the EMod, VMod, or AAT and that certain medically necessary upgrades/repairs are available only on a case-by-case basis with prior approval from New York State Department of Health. I understand that this EMod/VMod/AAT is being provided because it is medically necessary, and that the most costeffective option is being selected to meet this need. Should I request any upgrade in materials, I will be solely responsible for any associated fees inclusive of material costs, labor, etc. It is my responsibility to arrange a separate payment agreement with the vendor, if needed, for the payment of any upgrade requests. I understand that I must retain a copy of any warranties, if applicable, be familiar with their content, and follow their requirements. I understand that I am responsible for upgrading my homeowner’s and/or car owner’s insurance to include replacement coverage of the modification, if appropriate. I understand that while the EMod, VMod, and AAT is in development or being processed, and the participant’s circumstances change; enters hospital, nursing home, loss of Waiver or Medicaid eligibility, death, etc.; the project process may be stopped and or closed. I understand neither the New York State Department of Health nor the Financial Management Service (FMS) is responsible for removal of an installed environmental modification. I understand that neither the New York State Department of Health nor the Financial Management Service (FMS) provider is financially responsible for damage done to a member’s home or vehicle as a result of the modification. Participant’s Name (Print) Participant’s Signature Date | Parent/Caregiver’s Name (Print) | Parent/Caregiver’s Signature | Date | | --- | --- | --- | Home/Vehicle Owner’s (Print) Home/Vehicle Owner’s Signature Date (If different then above) Participant’s Health Home HHCM/C-YES’ Name (Print) HHCM/C-YES’ Signature Date SECTION II – For Change in Project Scope Only When a change in project scope is required after having previously completed and signed Section I above, the Waiver Partici

FAQs

What must Section I be completed to confirm agreement?

Section I requires initialing each item and signing at the end of Section I to show agreement with the waiver project terms and restrictions for EMod, VMod, and AAT.

When should Section II be used?

Section II is used only when a change in project scope is needed after Section I has already been completed and signed.

Are participants allowed to make changes directly with the contractor/provider?

No. The agreement states that participants are not permitted or authorized to make changes or address project issues directly with the contractor/provider.

Sep 16, 2026

Uploaded by Graffin