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.

Consumer Directed Personal Assistance Program Fiscal Intermediary
  • An entity that has a contract with a social services district to provide wage and benefit processing for consumer directed personal assistants and to perform the other 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: 9/2018


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.