How to Fill Out and Submit the CDPAP Consumer Agreement Form

The CDPAP consumer agreement form is the contract you sign with your Medicaid managed care plan (or, if you’re fee-for-service, your local Department of Social Services) that spells out your responsibilities as the person directing your own home care under New York’s Consumer Directed Personal Assistance Program. You fill it out by entering your identifying information in the header, reading through the four sections that list the duties of each party, and signing and dating the bottom along with your designated representative if you have one. You then return it to the plan or agency that gave it to you, alongside the rest of your enrollment paperwork.

The agreement itself is short. What makes it consequential is what you’re agreeing to: that you (or your designated representative) will act as the employer of your personal assistants, and that you understand Public Partnerships LLC (PPL) will handle payroll and tax withholding as the statewide fiscal intermediary.¹

Which Version of the Agreement You Sign

There are two versions, and which one you use depends on how you get your Medicaid.

If you’re enrolled in a Medicaid Managed Care plan, you sign the “Consumer Directed Personal Assistance Program Agreement Between the Consumer/Designated Representative and the Health Plan.” Your managed care plan provides this form.²

If you receive Medicaid on a fee-for-service basis, you sign a similar agreement with your local Department of Social Services. Separately, PPL as your fiscal intermediary must also obtain a signed agreement with you covering your responsibilities under 18 NYCRR § 505.28.³

If you’re unsure which form applies, ask the entity coordinating your CDPAP enrollment. Managed care members should call their plan; fee-for-service recipients can call the Department of Health at 518-474-5888. PPL enrollment questions go to 1-833-247-5346.

What’s Inside the Four Sections

The agreement is organized into four sections. Read all of them before you sign, because the substance sits in Sections II and III.⁴

Section I is the program overview. It describes how CDPAP works and what the agreement is meant to cover. No action required from you beyond reading it.

Section II lists the consumer and designated representative responsibilities in eighteen numbered items. These are the duties you are personally committing to, and they include recruiting and supervising your personal assistants, verifying timesheets, arranging substitute coverage when a PA is unavailable, and working with PPL as your fiscal intermediary.

Section III adds two items that apply only when a designated representative is involved. One of them is being available for scheduled assessment visits.

Section IV lists ten items covering the health plan’s own obligations, such as authorizing services and processing your plan of care. This section is what the plan is committing to on its side.

Filling Out the Form

The completion steps themselves are straightforward.

Start with the header. Enter your full legal name as it appears on your Medicaid record. If a designated representative will be directing your care (either because you’ve chosen to delegate authority as a self-directing consumer, or because you’re not self-directing and need one), enter their name in the designated representative field. Enter the name of your health plan.

Read through Sections I and IV so you understand the program framework and the plan’s obligations. Then read Sections II and III carefully. Each numbered item in Section II is a duty you are agreeing to carry out, and by signing you are attesting that you understand your role as the employer of your personal assistants, including that you are responsible for training them, scheduling their hours, and attesting to the accuracy of their timesheets.⁵

At the bottom, sign and date. If you have a designated representative, they sign and date as well. The health plan (or the LDSS, for fee-for-service consumers) signs on its side.

If you want help completing the paperwork, CDPAP facilitators are optional organizations that assist consumers with the enrollment process. You can request one by submitting the Optional Facilitator Selection Form available through the Department of Health’s CDPAP webpage. Using a facilitator does not change your obligation to work with PPL as your fiscal intermediary, and it does not shift any of the responsibilities in Section II away from you.

Submitting the Agreement

Return the signed agreement to whoever gave it to you. Managed care members submit it to their health plan. Fee-for-service consumers submit it to their local Department of Social Services. If a facilitator is helping you, they can transmit the paperwork on your behalf.

The consumer agreement is one piece of your CDPAP enrollment, not the whole thing. On its own, a signed agreement does not authorize services or allow your personal assistant to start working. You’ll also need a completed physician’s order (Form DOH-4359), an in-home assessment through the New York Independent Assessor Program, a formal notice of determination authorizing your hours, and separate PA registration paperwork with PPL before your assistant can be paid for a shift. Plan to submit the consumer agreement alongside the physician’s order rather than waiting for one to clear before starting the other.

What You’re Committing To After You Sign

The signature is the easy part. The obligations in Section II run for as long as you’re in the program, and they mirror the ongoing consumer responsibilities set out in 18 NYCRR § 505.28(h).⁵

You are responsible for recruiting enough personal assistants to cover your authorized hours. You train each one. You set their schedules. If a PA isn’t working out, terminating them is your call.

You verify every timesheet and submit it to PPL according to their procedures. Your attestation is what allows the PA to be paid, so accuracy matters. Personal assistants cannot claim hours for time you spend admitted to a hospital or other healthcare facility, except for the date of admission and the date of discharge.

When a PA calls out sick or is otherwise unavailable, finding backup coverage is your responsibility, not the plan’s and not PPL’s.

You must notify your LDSS or managed care plan promptly if your medical condition changes, if you are hospitalized, or if your address or phone number changes. You also have to notify PPL of any changes to a PA’s employment status.

If a designated representative signed the agreement with you, Section III’s two additional items apply to them, including being present for scheduled assessment visits. A designated representative takes on the full set of consumer responsibilities on your behalf: recruiting, training, scheduling, and supervising your personal assistants.

Who Can Sign as a Designated Representative

If you can direct your own care, you’re considered a self-directing consumer and may optionally delegate authority to an adult designated representative by naming them on the agreement. If you are not self-directing, you must have a designated representative, and they must be a parent, legal guardian, or a responsible adult surrogate approved by your local social services district or managed care plan.⁵

For non-self-directing consumers, expect the plan or LDSS to ask for documentation of the representative’s legal authority, such as guardianship papers, before it accepts the signed agreement.

If the Agreement Doesn’t Match Your Assessment

The agreement you sign is read alongside your physician’s order and the results of your Community Health Assessment. Inconsistencies slow things down. If your physician’s order describes you as fully mobile but the nurse conducting your assessment observes otherwise, or if the self-directing status marked on the physician’s order conflicts with your naming a designated representative to direct care, expect the plan or LDSS to come back with questions before it issues a notice of determination. Reviewing the physician’s order for accuracy at the doctor’s appointment, and making sure the designated representative fields on the consumer agreement match what the physician marked, will save you a round of back-and-forth.

1
New York State Department of Health. Consumer Directed Personal Assistance Program
2
New York State Department of Health. CDPAP Member/DR/MCO Agreement
3
New York State Department of Health. Administrative Agreement for the Provision of Fiscal Intermediary Services for the Consumer Directed Personal Assistance Program
4
New York State Department of Health. Consumer Directed Personal Assistance Program Statewide Fiscal Intermediary Policy for Medicaid Managed Care Plans
5
Legal Information Institute. New York Codes Rules and Regulations Title 18 505.28 – Consumer Directed Personal Assistance Program