Enroll in Home Health Care Services
Here you can find and download the form you need.
Enrollment Forms
Medical Request for Home Care – M11Q Form (pdf)
Form HCSP-M11Q, Medical Request for Home Care, is a document that is used to apply for personal home care and contains information regarding the patient’s medical condition. A New York State licensed physician is only available to conduct a medical examination and sign this form.
Physician Form DOH 4359
(pdf)
Form DOH-4359, Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services, is a document that can be used by individuals who would like to apply for certain types of assistance such as home care, help with skilled or personal tasks, housekeeping, etc.
CFEEC Evaluation Request Form (pdf)
The Conflict Free Evaluation and Enrollment Center (CFEEC) decides if you can join a Managed Long Term Care (MLTC) plan. The CFEEC is a program of New York State Medicaid. The CFEEC sends a nurse to your home to evaluate whether you need long term care services such as home care.
HIPAA Release
(pdf)
The HIPAA Privacy Rule requires that an individual provide signed authorization to a covered entity, before the entity may use protected health information (PHI). In accordance with the Privacy Rule, health care providers may use PHI without the patient’s authorization, for treatment purposes.