LPHA Attestation Form Guide to Edits

• Guide also available in Portable Document Format (PDF)

Effective April 2023, the Licensed Practitioner of the Healing Arts (LPHA) Attestation Form has been revised for clarity and ease of use.

Changes to the Form sections and fields are outlined in the chart below; new information is bolded:

Form Section	Update
Instructions	Split Instructions section into "PURPOSE" and "REQUIREMENTS of the LPHA Completing this Form" subsections to clarify additional details on the LPHA Attestation SED Form.
	Changed Licensed Practitioner of the Healing Arts (LPHA) form to Licensed Practitioner of the Healing Arts (LPHA) Attestation - Serious Emotional Disturbance (SED) Form.
	New text added: for a Medicaid (or Medicaid eligible) member <21 years of age for children/youth enrolled in Health Homes Serving Children or referred to the Child and Youth Evaluation Services (C-YES).
	Changed language referring to three Target Populations to only refer to the SED Target Population.
	New text added: The LPHA Attestation Form is the required document to verify the child/youth meets criteria for SED and the Risk Factors for the Target Population.
	Removed following language: Functional Criteria will be completed by the HHCM or C-YES and be considered as part of the LOC determination prior to the Medicaid (or Medicaid eligible) member receiving HCBS services.
Instructions	New subsection added: Requirements of the LPHA completing this form.
	New text added: The LPHA must attest that the member meets the SED Target Population and Risk eligibility requirements as outlined in the sections below AND must provide clinical documentation to the care manager to receive HCBS.
	New text added: This Attestation form MUST be filled-out by a Licensed Practitioner of the Healing Arts (LPHA) who has the ability to diagnose within their scope of practice under NY State law OR to be filled-out by a Licensed Practitioner who is under the supervision of a LPHA who has the ability to diagnose within their scope of practice under NY State law as outlined on the last page of this form.
	New text added: The LPHA must determine in writing by the completion of this attestation that the child, in the absence of HCBS, is at risk of institutionalization (i.e. , hospitalization) due to their mental health needs OR unable to return to their community due to their mental health needs.
	New text added The HHCM/C-YES is required to retain supporting documentation with the LPHA form in the member's case record to demonstrate HCBS eligibility. * Note: The completed LPHA form alone will not be sufficient for HCBS eligibility without the supporting documentation.
Instruction	New text added: Prior to the Children's HCBS Level of Care Determination being completed and this LPHA form being signed and attested, the potential HCBS member must first be determined to meet the SED determination criteria as outlined by the Office of Mental Health (OMH) requirements . Documentation of such needs and diagnosis(es) are to be provided with this LPHA Form. The LPHA Attestation Form is the required document to verify the child/youth meets criteria for of SED and the Risk Factors for the Target Population. The HHCM/C-YES are responsible for the completion of the Child and Adolescent Needs and Strengths (CANS-NY), which includes functional criteria, and is also part of the HCBS Level of Care determination process prior to the Medicaid (or Medicaid eligible) member receiving HCBS.
Instructions	New text added: To assist the LPHA to complete the attestation, the HHCM/C-YES can provide supporting care management documentation, with consent, for Target and Risk Factors to the LPHA. This may include Individualized Education Program (IEP), Residential Treatment Facility (RTF), or Residential Treatment Center (RTC) discharge paperwork, hospital discharge paperwork/plan, school reports, and/or diagnosis from another provider to inform the determination of whether the child meets the required risk factors.
	Removed sentence: This form is to be completed annually (365 days).
Instructions	Removed the following list items due to changes in the formatting of the fillable sections: Section A - MUST be completed. The LPHA must complete ONE of the following sections B, C, or D. The Medicaid (or Medicaid eligible) member should be identified in ONE of the following Target populations, Serious Emotional Disturbance (SED), Medically Fragile (MF), or Developmentally Disabled (DD), which correspond to Sections B, C, or D respectively. Risk will be identified within each of Sections B, C, or D based on the Target population identified. Section E MUST be completed for ALL target populations.
Section A	Combined all items from the previous version of the form's Section A, B, and E.
Section B: Serious Emotional Disturbance (SED) Target Criteria	Is now Section A: Serious Emotional Disturbance (SED) Target Criteria and more information on the SED Target Criteria can be found in the HCBS Waiver Enrollment Policy.
	New text added: *If the HHCM already had the Health Home SED determination Form completed within the last year by an LPHA for Health Home enrollment, this should be shared with the LPHA (if different) completing this attestation Form to assist and share information.
	Language change: Diagnosis Category changed to Diagnosis Cluster.
Section B: Serious Emotional Disturbance (SED) Target Criteria	New text added to item 3: The Medicaid member has experienced functional limitations due to serious emotional disturbance over the past 12 months on a continuous or intermittent basis.
	Combined last two bullets for item 3: self-direction/self-control; or ability to learn.
	New text added to item 5: The child/youth must be SED as determined by a Licensed Practitioner of the Healing Arts (LPHA) who has the ability to diagnose within their scope of practice under NY state law OR to be filled-out by a Licensed Practitioner who is under the supervision of a LPHA who has the ability to diagnose within their scope of practice under NY State law. The LPHA completing and signing this form must also be actively working with, has previously worked with the member in a clinical capacity within the last year (12 months), or who has completed a comprehensive evaluation in order to verify diagnoses and determine the child meets SED criteria. The LPHA, or Licensed Practitioner under the supervision of a LPHA, signing this form has determined that the child/youth (in the absence of HCBS) is at risk of institutionalization (i.e., hospitalization or nursing facility placement) due to their mental health needs OR is unable to return to their community due to their mental health needs.
Section B: Serious Emotional Disturbance (SED) Target Criteria	Definition of terms changed to only include Institutionalization and Multi-systems involvement.
	Updated definition of Multi-systems involvement: is defined as two or more child-serving systems, one of which must be involvement in the children's mental health system and at least one other system, as outlined below. If the member is receiving more than one mental health service (CFTSS, clinic, etc.), this would only count as one system involvement, inclusive of school-based behavioral health services.
	Paragraph added to included sub bullets examples of multi-systems involvement.
	New text added: However, multi-systems involvement does not include systems/services that all children should receive, such as school or primary care services.
	New text added: Enrollment in a Medicaid managed care plan, Health Homes/C-YES, HCBS, or other care coordination services also does not count toward multi-systems involvement. For additional examples of multi-systems involvement, please refer to the LPHA section of the Waiver Enrollment Policy.
Section B: Serious Emotional Disturbance (SED) Target Criteria	New text added: Note: Documentation of multi-systems involvement must be submitted along with the LPHA Form to meet the risk factor eligibility portion of the HCBS eligibility determination).
	New text added: * Please note that children/youth with an I/DD or SUD diagnosis must have a co-occurring qualifying mental health diagnosis, meet the SED criteria, and be at risk of hospitalization/out of home placement due to their mental health needs, in order to be enrolled in HCBS under the SED Target Population.
Section C: Medically Fragile (MF) Target Criteria	Removed.
Section D: Developmental Disability who are Medically Fragile (DD/MF) Target Criteria	Removed.
Section E: LPHA Information and Signature	Is now Section A: Serious Emotional Disturbance (SED) LPHA Information and Signature.
	New text added: I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and that this form was completed based on my ongoing treatment and/or clinical evaluation of the child noted above and supported by accompanying materials.
Section E: LPHA Information and Signature	Fillable Narrative box moved to the end of Serious Emotional Disturbance (SED) LPHA Information and Signature section.
	Added fillable affiliated organization.
	Added fillable "yes" and "no" check box item for the following question: "Are you under the supervision of an LPHA?"
	Added fillable item for the following question: "If yes, provide your supervisor's name and License No."
	Added fillable item for the following question: "Which of the following best describes the type of clinician you are:"
	New text added: *For this response, please attach any relevant supporting document.
Section E: LPHA Information and Signature	New text added: In order to comply with conflict-free care management requirements, the attesting LPHA may not be a supervisor / director or leadership position associated with oversight of the HHCM or C-YES or a designated HCBS provider agency/staff who is also affiliated with the HHCM agency who is completing the HCBS Eligibility Determination (for additional guidance, please refer to the Health Home Conflict Free Care Management Policy).
	New text added: If the child is identified as having significant needs by the HHCM/C-YES, and they have been unsuccessful in getting a treating clinician to complete the form, HHCM/C-YES may contact the county Children's Single Point of Access (C-SPOA) for assistance. The C-SPOA can work with the HHCM/C-YES to collect required information to complete/sign the form. Documentation will be required to demonstrate efforts the member/family and care manager has attempted to obtain treatment.
	New text added: This form was completed by the county C-SPOA based on documentation review and information gathering by the HHCM/provided by the treating LPHA.
	Fillable section added for the following: County Name of LPHA Designee LPHA Signature LPHA License #

Please direct your questions to BH.Transition@health.ny.gov.