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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.  


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Provider Index > Personal Care Agency (PCA) > Personal Care Agency and Consumer Directed Personal Assistance Program Fiscal Intermediary

Provider Enrollment & Maintenance



NOTE: Managed Care Only (non-billing) CDPAP-FIs who are not currently enrolled with NYS Medicaid must enroll to continue participating in an MCO Network.

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

Consumer Directed Personal Assistance Program Fiscal Intermediary: An entity that has a contract with a social services district or managed care organization to provide wage and benefit processing for consumer directed personal assistants and to perform the fiscal intermediary responsibilities specified in subdivision (i) of 18 NYCRR ยง 505.28.


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: 4/2021


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.