NY Medicaid  
home | self help | glossary | site map

ENROLLMENT FORM

Category(s) of Service: 0264

If you are ALREADY ENROLLED and need to change your corporate or correspondence address, click here.

  Include the DOH Letter which waives the application fee for your LDSS


Print Instructions

Provider Index > Community First Choice Option (CFCO)

Provider Enrollment & Maintenance



A Local Department of Social Services enrollment (LDSS) for CFCO Services
The LDSS will coordinate and reimburse CFCO services directly to providers for the following services, and will be available 01/01/2020:
  • Vehicle Modification
  • Environmental Modification
  • Home Delivered Meals
  • Assistive Technology
  • Community Transitional Services
  • Moving Assistance
  • Skill Acquisition, Maintenance and Enhancement (SAME)



Complete this Enrollment Form if you are:
  1. Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
  2. Responding to a letter instructing you to REVALIDATE your enrollment, or
  3. Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
  4. Reporting an OWNERSHIP CHANGE, or
  5. Reporting a RECEIVERSHIP

INSTITUTION Enrollment Form

Last Updated: 1/2020


Supplemental Information

If you have any questions or concerns, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email.