Complete the form below to check eligibility and begin the Medicaid approval process for the Personal Care Aide (PCA) services. Providing accurate information will help ensure a smooth application process.

If the patient who requires the care cannot complete the form due to age, disability, or other reasons, a caregiver or trusted individual may fill it out on their behalf.

Patient Requirements:

They need to have a long-term health condition or disability that requires assistance with daily living activities.
New York State residents.

Caregiver Requirements:

Must be 18+ and authorized to work in the U.S.
Must complete an initial health assessment.
Must acquire a PCA license.

We are dedicated to safeguarding your privacy and will use the information provided to assess your or your family member’s eligibility for Long-Term Care Services.

What Happens Next?

After you submit the form:

Our team will review your application promptly.
We’ll contact you to discuss the status of your application, outline the following steps, and answer any questions.

If you have any questions or need assistance with the form, contact us:
📞 Call us at 718-395-6329
📧 Email us at contact@cdpaphc.com

Patient's Contact Information

Providing the contact information of the individual requiring care is essential to proceed and determine their eligibility.

First Name *

Last Name *

Gender *MaleFemale

Phone Number *

Email Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Patient's Insurance Information

Please provide the insurance details of the individual requiring care.

What is the patient's Medicaid Client ID Number (CIN) (e.g., AA11111A)?
If Medicaid coverage is unavailable or the CIN cannot be located, please provide the Social Security Number (SSN) instead.

Medicaid Client ID Number (CIN) or SSN *To locate the CIN (preferred), refer to the example provided below by scrolling down.0 / 9

Birth Date *

Patient's Health Situation *0 / 300

Caregiver Contact Information

Please provide the contact information of the individual who will be the paid caregiver for the patient requiring care.

First Name *

Last Name *

Relationship with the patient *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Email Address *

Phone *

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id number — The Medicaid Client ID Number (CIN) is preferred and can be found on the front of the patient’s NYS EBT card, as shown in the example above. If you cannot locate the CIN, you may use their SSN instead.

PCA Family Caregiver Form