The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Q9tttYgoZtTdtnibdbNfL5VsYFohecqQiXUgfxvKdbUYzcV7TGrFJMSNs9nYm83UsD8wnY

Online HCBS Referral Form

Hello and welcome to the DSDS Online HCBS Referral Form!

A referral for HCBS is required in order to initiate an assessment to determine if eligible participants meet Skilled Nursing Facility Level-of-Care for State Plan Services, Aged & Disabled Waivered Services, the Adult Day Care Waiver, or the Independent Living Waiver administered by the Division of Senior and Disability Services.

Please note: 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.

Please note: A face-to-face assessment conducted by DSDS is required prior to receiving services.

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

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.