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Referral for Services (RFS) Form

IDD/DD Diagnosis 
Our services are geared for IDD/DD population primarily, if you are over the age of 21, seeking services or evaluations not under the auspices of OPWDD or in support of application to benefits related to IDD, we will not be able to accept your referral at this time.
IDD Diagnosis Required
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Please call YAI 212-273-6100 Ext. 4998

IDD diagnosis required...
Most services require an IDD diagnosis, however, we are currently accepting referrals for Psychotherapy (insurance pending).

Provide Caregiver Information
In order to complete the request for services, you will need to provide contact information for the caregiver in addition to the patient information.
Caregiver Information Required
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In order to complete the request for services, you will need to provide contact information for the caregiver in addition to the patient information.

Please gather the caregiver information then come back and complete this form  If unable to provide FULL caregiver/patient information, please contact 212-273-6100 Ext. 4998 to clarify what is needed.
Caregiver Information 
Please provide the caregiver information below.
Caregiver Information 
Please provide your contact information below.
Legal Guardian information
Please provide information for the legal guardian below.
Care Manager as Referral Source 
Please provide your contact information below
Professional NonCare Manager as Referral Source
Please provide your contact information below
Care Manager (not Referral Source)
Care Manager Contact Information (CM Not Ref Source)
Please provide information about the patients Care Manager below
All Patient Info 
Patient Information
Description of Patient
Insurance Information

Medicaid Card Sample
(Example: "XX00000X")


Medicare 
Medicare Card Sample
Insurance Details
We do not accept Secondary or Private Pay for ongoing services such as Rehabilitation (OT/PT/Speech), Nutrition or Psychotherapy Services. If clinical service request will not be covered by insurance and is considered PRIVATE PAY a Financial Agreement/Counseling will be needed prior to scheduling
Insurance Information Required
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***In order to complete the request for services, you will need to provide either Medicaid, Medicare or private insurance information so that we can process the referral.

Please call 212-273-6100 x4998 or email article16referrals@yai.org if you have any questions, have no insurance coverage and are in need of Mental Health Evaluations only.
Reason For Referral


What behavioral concerns or symptoms are present to request psychotherapy services at this time?
Nutrition

PT
Please list medical/physical limitations or concerns affecting: areas of performance including safety during ambulation, transfers, positioning, etc.

OT
Please list medical/physical limitations or concerns affecting: activities for daily living, health management, work and productive activities

Speech Therapy
Please list medical/physical limitations or concerns affecting: cognitive/communication needs

Speech Therapy - AAC
Please list medical/physical limitations or concerns affecting: assessment, diagnosis or train on the use of a device
Speech Therapy - Dysphagia
Please list medical/physical limitations or concerns affecting: oral motor issues affecting swallowing/feeding
Stop Sign

*You will need to select at least 1 service for this Referral request to go through. Please make sure one service above is selected.

Attestation


Hidden Fields