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 you an Enrollment consent packet to get you started on the process. To initiate the OPWDD Process, you must complete this form in its entirety

Person in Need of Care Management

First Name *

Last Name *

Date of Birth *

Gender *

TABSID Number

Do you have Medicaid? *

Yes

I don't know

Medicaid Cin# *

Insurance/MCO Medicaid Managed Care Program? *

Yes

What Managed Care Program? *

Other Managed Care Program *

Primary Care Provider's First Name *

Primary Care Provider's Last Name *

Is this person enrolled in another CCO/Agency? *

Yes

Which CCO/Agency? *

Is the person currently living in New York State? *

Yes

Current living arrangement? *

Address

Street Address *

City *

State *

ZIP Code *

County *

Primary Contact or Authorized Signer

Same person as completing form? *

Yes

If the person in need of services is over 18, are they able to independently sign (Authorized Signer) their own consents? *

Yes

Relationship with the person? *

If other relative, what is your relationship? *

First Name (Primary Contact) *

Last Name (Primary Contact) *

Email (Primary Contact) *

Phone (Primary Contact) *

Preferred Language *

How did you hear about Care Design NY? *

Person Completing Form

First Name *

Last Name *

Email *

Phone *

Notes and/or Comments

First Name

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?

Person in Need of Care Management

Address

Primary Contact or Authorized Signer

Person Completing Form

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