Personal Care Services benefits have been added to the Medicaid managed care benefit effective 8/1/11. Below are some of the forms required to be completed.

For new referrals, physicians will need to fax the completed order form to Fidelis Care at 1-877-433-7085 before an in-home assessment can be scheduled.

• Personal Care Benefit Physician's order form (Outside of New York City) DOH 4359 (2010)
  http://www.health.state.ny.us/health_care/medicaid/publications/docs/gis/10oltc-006att.pdf
   
• Instructions for form (Outside of New York City) DOH 4359 (2010)
  http://www.health.state.ny.us/health_care/medicaid/publications/docs/gis/10oltc-006.pdf
   
• Personal Care Benefit Physician's request form (New York City) Form M-11q (10/09)
  http://www.nyc.gov/html/hra/downloads/pdf/M11q.pdf
   

Assessment Forms:

• Home Assessment Abstract (Outside of New York City) form LDSS-3139
  http://www.health.ny.gov/health_care/medicaid/reference/tbi/docs/e1.pdf
   
• Nurse's Assessment Visit Report (New York City) M-27r
  http://www.fideliscare.org/downloads/pcs_nursesassessment.pdf
   
• PERs Assessment/Reassessment Checklist (Outside of New York City)
  http://www.fideliscare.org/downloads/pcs_persassessment.pdf
   
• Personal Emergency Response Services (PERS) Evaluation Form (New York City)
  http://www.fideliscare.org/downloads/pcs_personalemergency.pdf