Request to Become an Ancillary Care Provider

Requesting Participation as:

Select all that apply.

Adult Day CareAdult HomeAids Adult Day CareAmbulatory Surgery CenterAssertive Community TreatmentAssisted LivingAssisted Living TechnologyAudiology Behavioral HealthCertified Outpatient Rehab FacilityCommunity IntegrationCommunity Transitional ServicesConsumer Directed Personal Assistance ServicesDay Treatment & Continuing DayDiagnostic and Treatment CenterDialysis ServicesDurable Medical EquipmentEnvironmental ModificationsFamily PlanningHome & Community Support ServicesHome Delivered MealsHome Health CareHospitalInpatient Mental HealthLaboratoryMedical Social WorkMobile HealthMoving AssistanceOrthotics and ProstheticsOutpatient Mental HealthPersonal Care WorkersPersonal Emergency Response SystemPositive Behavioral Interventions & SupportPrivate Duty NursingRadiologyRespiratory TherapyRespiteSkilled Nursing FacilitySleep StudiesSocial Day CareStructured Day ProgramSubstance AbuseUrgent Care Center

Organization Name *

Organizational NPI*

This is a required 10-digit field.

Organizational Tax Identification Number (TIN)*

This is a required 9-digit field.

Street Address*

Street Address 2

City*

State*New York

Zip/Postal Code*

Telephone Number*

This a required 10-digit phone number.

Who should we contact if there are any questions?

Full Name*

Telephone Number*

This is a required 10-digit phone number.

Email*

Should the decision letter be sent to the address listed above?*YesNo