ENROLLMENT FORM

Category(s) of Service: 0264

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

  Application Fee is REQUIRED. Click here for more information.  


Print Instructions

Provider Index > Personal Care Agency (PCA)

Provider Enrollment & Maintenance



Personal Care Agency Provider: Provides services such as housekeeping, meal preparation, bathing, toileting and grooming to eligible individuals.

Consumer Directed Personal Assistance Program (CDPAP) Provider
  • This Medicaid program provides services to chronically ill or physically disabled individuals who have a medical need for help with activities of daily living (ADLs) or skilled nursing services.
  • Services can include any of the services provided by a personal care aide (home attendant), home health aide, or nurse. Recipients have flexibility and freedom in choosing their caregivers.
  • The consumer or the person acting on the consumer's behalf (such as the parent of a disabled or chronically ill child) assumes full responsibility for hiring, training, supervising, and - if need be - terminating the employment of persons providing the services.



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: 11/2017


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.