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NYIA Evaluation Request Form

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Managed Care Plan Information

Plan Member Information

Name*
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The Medicaid ID Number must be formatted with 2 letters followed by 5 digits and 1 letter (XX0000X) . Please enter with the proper format.
Gender*
Permanent Address*
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Acknowledgement / Release of Medical Information

I understand:

That I must join a Managed Long Term Care Plan (MLTC Plan) to receive Medicaid community-based long term care (cbltc) services in my county.

The differences between a Medicaid health plan and a MLTC Plan and that I will lose some benefits.

I may not be able to see my doctors if I change to a MLTC Plan.

The Conflict Free Evaluation and Enrollment Center (CFEEC) must determine I need more than 120 days of cbltc services and that I am nursing home eligible, before I can join a plan. A CFEEC nurse will contact me to schedule an evaluation.

I give my Provider permission to give all needed medical information only if it is relevant to my request to transfer to a long term care plan. This may include any disability information needed to confirm needed services that are not available in my Medicaid health plan.
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