Services Enrollment Form - Care Design NY

Interested in receiving Care Coordination Services?

THE FIRST STEP IS TO COMPLETE THE FORM BELOW - UPON RECEIPT, WE WILL SEND INFORMATION AND GET YOU STARTED WITH THE PROCESS.

PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE SO WE CAN BEST ASSIST YOU.

Name of person seeking care management services? *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Date of Birth *

Is this person under the age of 18? *

Yes

Is this person over the age of 21? *

Yes

If the services are for someone else, what is your name and relationship to the person?

The person's phone number *

Email *

What County do they live in? *

Who should we correspond with for the enrollment process? *

What is their phone number? *

What is their email? *

If someone referred you to Care Design NY, who referred you?

We can send an enrollment packet by regular mail or email. How would you like us to send it? *

Please answer the following about the person to the best of your ability:

Have they been determined eligible for OPWDD Services? *

Yes

I don't know

Do they have Medicaid? *

Yes

I don't know

What is their Medicaid number? *

Example: AA11111A

Do they have Medicare? *

Yes

I don't know

What is their Medicare number?

Name of primary care physician (PCP): *

Name of Medicaid Managed Care plan, if enrolled in one:

Is the person seeking services currently in the hospital, a nursing facility/rehabilitation center, foster care, a residential school, or homeless shelter? *

Yes

I don't know

Notes/Comments

reCAPTCHA Checkbox *

Website

We thank you for your interest in Care Design NY. One of our Enrollment Coordinators will connect with you as soon as possible to provide you with further information about the enrollment process. If you have additional questions, please call our central enrollment number at 518-320-8400. We look forward to working with you. Please note that all inquiries are answered in the order received, so your patience is greatly appreciated.

Interested in receiving Care Coordination Services?

THE FIRST STEP IS TO COMPLETE THE FORM BELOW - UPON RECEIPT, WE WILL SEND INFORMATION AND GET YOU STARTED WITH THE PROCESS.

PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE SO WE CAN BEST ASSIST YOU.

Please answer the following about the person to the best of your ability:

Contact Care Design NY

518-235-1888

Emergency After Hours: 1-877-855-3673 The emergency after hours number will only be in operation after 5:00pm to 8:30am on business days, weekends, and Care Design NY holidays. Please only use emergency number for urgent matters that cannot wait until the next business day.

Care Design NY

Interested in receiving Care Coordination Services?

THE FIRST STEP IS TO COMPLETE THE FORM BELOW - UPON RECEIPT, WE WILL SEND INFORMATION AND GET YOU STARTED WITH THE PROCESS.PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE SO WE CAN BEST ASSIST YOU.

Please answer the following about the person to the best of your ability:

THE FIRST STEP IS TO COMPLETE THE FORM BELOW - UPON RECEIPT, WE WILL SEND INFORMATION AND GET YOU STARTED WITH THE PROCESS.

PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE SO WE CAN BEST ASSIST YOU.