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.

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

Page 1 of 11

Loading... Loading...
You have selected an option that triggers this survey to end right now.
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.