This is the form used by the New York City Human Resources Administration for doctors to request personal care services through Medicaid for people who are excluded or exempt from Managed Long Term Care. This means it is for people in the OPWDD, TBI or NHTDW waivers, who require only Housekeeping services of up to 8 hours/week or who are under age 21. The form was updated 12/2014. This is a fillable version. THe original PDF can be downloaded at http://www.nyc.gov/html/hra/downloads/pdf/services/micsa/m_11q.pdf.

NYLAG Evelyn Frank Program "Appendix" of documents on MLTC and FIDA for CLE 4/20/15 - includes helpful lists of plans, forms, and a Troubleshooting guide.

Fact sheet written by New York Legal Assistance Group Evelyn Frank Legal Resources Problem addressing common problems encountered by those trying to enroll in MLTC plans, especially where they have a spend-down OR are trying to leave a nursing home. Learn how to avoid delays in enrollment. Includes helpful forms, focused on NYC but can be adapted statewide (updated April 15, 2015)

This is the cover sheet to used for MLTC NHED

This is the MLTC Provider Relations Unit cover sheet to be used

This is a list of Medicaid Offices throughout NYC's 5 boroughs, along with a list of MICSA/MAP sites with certified application counselotrs

This is the spousal refusal form for Suffolk County residents

This is the form in both English & Spanish agreeing to participate in the Medicaid Pay-In Program

This explains the Excess Income Program for clients whose incomes exceeds the Medical Assistance income limits

This is a redacted MAP-259p form to act as a guide for purposes of Medical Assistance application/recertification