How to Fill Out and Submit the NY DOH Home Care Form

New York’s DOH-4359 home care form — formally the Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services — is the medical certification your doctor completes so you can receive Medicaid-funded home care through Personal Care Services or the Consumer Directed Personal Assistance Program (CDPAP). You fill in your identifying information at the top, your provider completes the clinical sections based on an examination performed within the past 30 calendar days, and you submit the signed form to your local Department of Social Services office, or to the Human Resources Administration if you live in New York City, along with any Medicaid application materials.¹

Where to Get the Form

The DOH-4359 is available as a PDF from the New York State Department of Health website, attached to General Information System message 10 OLTC/006. Your local Department of Social Services office can also give you a copy.

One thing to check before you print it out: the DOH-4359 is not the only acceptable format. Local social services districts may use their own physician’s order form as long as it contains every element on the DOH-4359.² Call your county DSS office to confirm which version they want.

What You Fill In at the Top

The patient-identifying section is yours to complete. You enter your full name, date of birth, sex, complete mailing address, telephone number, Client Identification Number (CIN) from your Medicaid card, and Medicare number if you have one.³ Note that the form asks for your CIN, not your Social Security number. The CIN is printed on your Medicaid benefits card.

If you don’t yet have Medicaid, the DOH-4359 travels alongside a Medicaid application (Form DOH-4220), a Supplement A (DOH-5178A) if applicable, and the Attestation of Immediate Need (DOH-5786) if your situation calls for expedited processing.¹ Have those forms ready before your doctor’s visit so the whole package can move together.

What Your Doctor Fills In

The clinical sections are the bulk of the form, and they must be completed by a New York State licensed physician, physician assistant, specialist’s assistant, or nurse practitioner. If someone other than a physician performs the examination, their name, profession, and license number go in a separate field, but a physician must still sign the final order.³

Your provider documents:

Primary and secondary diagnoses with ICD codes.
A written description of your current medical and physical condition.
Your treatment plan, therapeutic goals, and prognosis.
Functional limitations, including any prohibited activities.
Whether you can direct your own care and whether you can summon help by any means.
Mobility status: independent, with devices, or with other assistance.
Bowel and bladder continence, and any catheter or colostomy needs.
All current prescriptions and over-the-counter medications with dosage, frequency, and special instructions, plus whether you can self-administer them.
Any modified diet or special nutritional needs.
Whether you need help with skilled tasks such as vital-sign monitoring, dressing changes, or glucose monitoring.
Social, family, home, or medical circumstances affecting your ability to function independently.³

Two rules on this section are easy to miss and hard to fix later. First, the examination the order is based on must have occurred within 30 calendar days of the date the physician signs the form.³ If too much time passes between the exam and the signature, the form is stale and you start over. Schedule the appointment with that window in mind and get the signature promptly.

Second, the signing physician is not to recommend a specific number of service hours. That determination is made later by the local district through its assessment process, not by the prescribing doctor.³ If your doctor writes in a number of hours, it will be disregarded and can slow the review.

How to Keep the Form From Being Sent Back

The form works best when your provider writes specific descriptions rather than checking boxes and moving on. Vague language like “needs help with ADLs” gives reviewers little to work with. Descriptions that spell out what you cannot do, why, and what happens without assistance carry the application forward. Bring hospital discharge summaries, specialist reports, and therapy notes to the appointment so your provider can reference exact dates and findings.

Before you leave the office, check that the physician’s signature, license number, and examination date are all filled in and legible. A missing license number or illegible signature is one of the fastest ways to have the form returned. Photocopy the completed, signed form for your own records before you hand off the original.

Where to Submit the Completed Form

If you live outside New York City, send the completed DOH-4359 and any accompanying Medicaid application materials to your local Department of Social Services office. If you live in any of the five boroughs, submit everything to the Human Resources Administration (HRA).¹ The form includes a line reading “PLEASE SIGN AND RETURN COMPLETED FORM WITHIN 30 CALENDAR DAYS OF EXAMINATION TO:” followed by space for the district’s address.³ Your local DSS or HRA office can confirm the exact mailing address or walk-in location.

What Happens After You Submit

Once the district or HRA has the physician’s order, a nursing assessment by a registered nurse from a certified home health agency or the local district must happen within five working days of the request. That nurse reviews and interprets the physician’s order, evaluates the specific tasks you need, judges how much help each task requires, and develops a recommended plan of care with you.⁴ An independent assessor, a registered nurse with at least two years of recent home health care experience, then performs an in-person assessment, typically in your home, and district staff complete a social assessment covering informal caregiver availability and alternatives.⁵

You will then receive a written notice stating whether services are authorized, at what level, or the reasons for a denial. Federal regulations require Medicaid eligibility determinations within 90 days for applicants whose eligibility is based on disability, and within 45 days for all other applicants.⁶ If you submitted the DOH-5786 Attestation of Immediate Need, the district must determine your eligibility for personal care services or CDPAP within 12 days of receiving all required paperwork.⁷

When You Will Need to File Another One

Once you are receiving services, you do not refile the DOH-4359 every year automatically. A new physician’s order is required when the one on file is more than 12 months old or when a new order is clinically indicated, such as after a significant change in your condition. At reassessment, the district follows the same independent assessment process to reauthorize services.⁸

If You Are Denied

If personal care services or CDPAP are denied, reduced, or discontinued, you can challenge the decision through a fair hearing with the New York State Office of Temporary and Disability Assistance. For a denial of Medicaid eligibility, you have 60 days from the notice date to request a hearing. If your existing services are being reduced or discontinued, request a fair hearing within 10 days of the notice to keep your services unchanged while the hearing is pending.⁹

If you are enrolled in a Medicaid managed care plan, you generally must file an internal plan appeal first, within 60 days of the adverse decision, before requesting a state fair hearing. After the plan denies your appeal, you have 120 days to request a fair hearing. The 10-day rule for continuing services applies at both stages.⁹ You can request a fair hearing by phone at 800-342-3334 or through the OTDA hearings portal at otda.ny.gov/hearings/request/.

1
New York State Department of Health. How to Apply for NY Medicaid
2
New York State Department of Health. GIS 10 OLTC/006 – Physician’s Order for use in the Personal Care Services Program and the Consumer Directed Personal Assistance Program
3
New York State Department of Health. DOH-4359 Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services
4
New York State Department of Health. 11 OLTC/LCM-1 – Personal Care Services Program Assessment Process
5
Cornell Law Institute. New York Compilation of Codes, Rules and Regulations Title 18 505.14 – Personal Care Services
6
Centers for Medicare & Medicaid Services. CMCS Informational Bulletin: Ensuring Timely and Accurate Medicaid and CHIP Eligibility Determinations at Application
7
New York State Department of Health. Immediate Need for Personal Care/Consumer Directed Personal Assistance Services Informational Notice and Attestation Form
8
New York Codes, Rules and Regulations. Personal Care Services (PCS) and Consumer Directed Personal Assistance Services Regulatory Text
9
Legal Aid Society. What You Need to Know About Medicaid and Fair Hearings