ERC Form and Application Updates
This page provides ICMS case managers and HSH program staff with the most current ERC forms and application process guidance for referrals to licensed residential care facilities.
Check back regularly as forms and CHAMP workflows are updated.
Current ERC Forms
The following forms are currently required for ERC assessments and applications. Always use the most current version of each form. Download links are provided for each document.
Note: With the updated CHAMP workflow, each required ERC form can now be uploaded individually under the Documents/ERC Documents section in CHAMP.
Request for ERC Assessment
Used by HSH facilities and other HSH specialized programs to request an assessment from the ERC Care Team of an individual who is likely appropriate for placement at a licensed residential care facility.
Updated: February 19, 2026
ERC Care Payment Responsibilities Form
Clients entering the ERC program with income, including but not limited to SSI, are expected to use their income to pay the monthly room and board rent at licensed residential care facilities. This form documents that understanding.
Updated: February 19, 2026
Physician’s Report — LIC 602A, LIC 602
The new version of the Physician’s Report, which must be submitted as part of an HSH/ERC Application. This updated form must also include an updated TB test result.
Updated: April 6, 2026
Application for ERC Referrals in CHAMP
The updated CHAMP workflow guide for completing and submitting an HSH Application for ERC referrals. Each required ERC form can now be uploaded individually under the Documents/ERC Documents section.
Updated: April 6, 2026
ERC Application Process Updates
The following updates reflect recent changes to ERC forms and the CHAMP application workflow. Review each update and ensure your team is using the most current forms and processes.
February 19, 2026 — New Request Form for ERC Assessment
A new Request for ERC Assessment form is now in use. This form is used by HSH facilities and other HSH specialized programs to request an assessment from the ERC Care Team of an individual who is likely appropriate for placement at a licensed residential care facility.
February 19, 2026 — New Care Payment Responsibilities Form
A new ERC Care Payment Responsibilities Form is now required. Clients entering the ERC program with income, including but not limited to SSI, are expected to use their income to pay the monthly room and board rent at licensed residential care facilities.
July 21, 2025 — New Physician’s Report (LIC 602A, 602)
The new version of the Physician’s Report (LIC 602A) must be submitted as part of an HFH/ERC Application. This updated form document must also include an updated TB test result.
July 21, 2025 — Updated CHAMP Application Workflow
With the updated CHAMP workflow, each required ERC form can now be uploaded individually under the Documents/ERC Documents section. The 809 form is still required for the HFH Application and must be received by fax or email.
About the Enriched Residential Care Program
The Enriched Residential Care (ERC) program supports individuals who are likely appropriate for placement at a licensed residential care facility. ERC provides placement and ongoing support for clients within the ICMS and FHSP programs.
Note: Clients entering the ERC program with income, including but not limited to SSI, are expected to use their income to pay the monthly room and board rent at licensed residential care facilities.
ERC Assessment Process
Referrals to ERC begin with a Request for ERC Assessment submitted by an HSH facility or specialized program. The ERC Care Team then evaluates whether the individual is appropriate for placement at a licensed residential care facility.
CHAMP Application Workflow
To complete an HFH/ERC Application in CHAMP, begin the Submit HFH Application workflow, complete the Application Form, select Enriched Residential Care as the Program Topic, upload all required documents, and save and finish the workflow.