Apply for CDPAP

Your Name *

Email *

Phone Number *

Patient’s Name *

Does the Patient currently have Medicaid? *

Patient’s Medicaid CIN Number *

Would you like to apply for New York State Medicaid? We can assist. *

Yes

No

Does the patient currently receive home care services? *

Yes

No

Please include details (hours, days, which specific Medicaid plan does the patient currently have?

Name of Personal Assistant *

Personal Assistant’s Email *

Personal Assistant’s Phone Number *

Patient’s Preferred Language *

Ready to Find Your Match?