Choose DHCARE as your CDPAP Facilitator

Please complete the form below with the consumer and Personal Assistant information to begin your transition to PPL with DHCARE NY as your PPL Facilitator

Consumer Name(Required)

Consumer First Name Consumer Last Name

Consumer Email(Required)

Consumer Tel #(Required)

Consumer CIN/Medicaid ID(Required)

Personal Assistant Name(Required)

Personal Assistant Phone number(Required)

Personal Assistant email(Required)

Is the Consumer self directing?(Required)

"Self-directing”, means that the Consumer has the ability to make choices about their own care.

Is Consumer currently receiving CDPAP services?(Required)

Consumer Primary Language(Required)

PPL Submission Form

Choose DHCARE as your CDPAP Facilitator

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