Welcome, Providers!

Fidelis Care would like to advise Providers of an update to the Private Duty Nursing (PDN) manual as of July 1, 2026.

Member Demographic Information Form

Detailed in section 6.11 of the Private Duty Nursing (PDN) manual, this form is to be completed by the Billing Provider. If support is needed for completion, members’ Care Manager should be contacted.

• The form includes a home safety attestation and applicable member information regarding school and day program.
• This form must be submitted with new PDN cases and with 12-month documentation renewal requests, along with the required documentation detailed in Section 6.1 of the PDN Policy Manual. 
• This form is required any time there has been a change to the information provided, submitted via change request to eMedNY per Section 9.1 of the PDN Policy Manual.
• The form must be dated no more than 90 days before the prior approval start date.
• Incomplete or missing forms will not be accepted and will delay the prior approval process.

Trained Caregiver Form

Detailed in section 6.12 of the Private Duty Nursing (PDN) manual, this form is to be completed by the Members’ Trained Caregiver(s).

• The form includes a training attestation statement, member household information, and the trained caregiver’s living situation, employment, and college status.
• At least one trained adult caregiver is required and cannot be a provider servicing the case (submit a separate form for any additional trained caregivers).
• This form must be submitted with new PDN cases and with 12-month documentation renewal requests, along with the required documentations detailed in Section 6.1 of the PDN Policy Manual.
• This form is required any time there has been a change to the information provided, submitted via change request to eMedNY, per Section 9.1 of the PDN Policy Manual.
• The form must be dated no more than 90 days before the prior approval start date.
• Incomplete or missing forms will not be accepted and will delay the prior approval process.

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist. Thank you for being a valued Fidelis Care partner in the provision of quality care.