Online HCBS Referral Form

Hello and welcome to the Home and Community Based Services (HCBS) Referral Form! The referral form is the first step to newly apply for Home and Community Based Services through the Division of Senior and Disability Services (DSDS). If you or the person being referred already receives HCBS through DSDS but is need of a change to those services, please do not complete this form and click here to complete the Person Centered Care Plan Change Request Form.

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Home and Community Based Services are designed to allow seniors and individuals with disabilities who meet nursing facility level of care an alternative choice to remain in their home or preferred environment. This means the person being referred is believed to have needs equal to those in need of nursing facility placement.

* must provide value

I understand and agree I or the person being referred would like to receive services in my/their home and has needs equal to those entering a nursing facility.

I do not agree

Home and Community Based Services can provide additional help to enhance an individual's current support system. HCBS is not an all-inclusive or total care program.

* must provide value

I understand and agree

I do not agree

This referral will be reviewed and if determined appropriate will be sent to the regional assessment team. The regional team will call to schedule an assessment with the person referred or guardian. An in-person assessment is required to determine eligibility prior to receiving services. Resources at the end of the survey should be reviewed to ensure the referred person is prepared for the assessment.

* must provide value

I understand and agree an in-person assessment will be required

I do not agree

It is illegal in the State of Missouri to willfully provide false information in an attempt to obtain any public assistance benefits, programs, and services. Any person who willfully provides false information in an attempt to obtain any public assistance benefits, programs, and services shall be guilty of the crime of stealing. Please reference Missouri Statue 205.967 for more information.

* must provide value

I understand

I do not agree

If you have any questions regarding these statements, please contact the HCBS Intake Call Center before completing the referral form. HCBSCallCenterReferrals@health.mo.gov

Note: Incomplete submissions will not be processed, please complete the entire form. Click 'Next Page' to proceed through the form.

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