The NYIA Assessment Request Form is what starts the process of getting a New York Medicaid member evaluated for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS). It has five sections, and in practice a managed care plan representative or a local Department of Social Services (LDSS) caseworker fills it out and submits it on the applicant’s behalf. A physician, nurse practitioner, or physician assistant completes the medical portion. Once NYIA receives the form, it schedules a two-part health assessment — a nursing evaluation and a clinical exam — that determines whether the person qualifies for in-home care.
Who the Form Is For
Any New York Medicaid member age 18 or older who wants PCS or CDPAS must be assessed by NYIA before services can be authorized. This is true whether you are enrolling in a Managed Long Term Care (MLTC) plan or requesting services through your local Medicaid office or a mainstream managed care plan.
Children under 18 do not use this form. They request CDPAS directly through their managed care plan using a form signed by their physician or nurse practitioner.
Applicants 21 and older also have to meet minimum needs requirements that took effect September 1, 2025. Under the general standard, you must be assessed as needing at least limited assistance with physical maneuvering for more than two activities of daily living (ADLs). If you have a dementia or Alzheimer’s diagnosis, the threshold drops to needing at least supervision with more than one ADL. These rules apply to initial assessments and reassessments occurring on or after September 1, 2025. If you were already authorized for or receiving PCS or CDPAS, or continuously enrolled in an MLTC plan as of that date, the earlier criteria still govern your case.
Filling Out the Form Section by Section
The standard form is numbered NYIA ASSESSMENT REQ FORM-0522. It has five sections, and each has a specific person responsible for completing it.
Section 1: Medicaid Health Plan Information
This identifies the applicant’s current Medicaid health plan and, if applicable, the MLTC plan the applicant wants to join. If the person is not yet enrolled in any plan, the current-plan field may be left blank or marked accordingly.
Section 2: Individual’s Identifying Information
Standard personal details go here:
- Full name and date of birth
- Medicaid CIN (Client Identification Number)
- Social Security number
- Home address, email, and phone number
- Authorized representative information, if someone is acting on the applicant’s behalf, including that person’s name, relationship to the applicant, address, email, and phone number
If an authorized representative is signing, a copy of the legal authorization document must be submitted with the form, unless it has already been provided to New York Medicaid Choice.
Section 3: Acknowledgement and Release of Medical Information
The applicant, or their authorized representative, signs and dates this section. The signature authorizes NYIA to obtain the medical information it needs to conduct the assessment. There are separate signature and date lines for the applicant and the representative; complete whichever applies.
Section 4: Health Care Provider Authorization
A physician, nurse practitioner, or physician assistant completes this entire section. It has two parts:
- Checkboxes indicating whether the applicant needs social and environmental supports (such as wheelchair ramps or grab rails), home delivered meals, or social day care
- Provider details: name, specialty, license number, clinic or practice name, address, phone, fax, and signature
Every field needs to be filled in. Incomplete provider information is one of the most common reasons forms come back, and each round trip delays the assessment.
Section 5: Managed Long Term Care Plan
The MLTC plan representative submitting the form completes this final section with their name, title, date, signature, and phone number. It applies only when an MLTC plan is handling the submission.
Submitting the Form
The standard form is submitted by the MLTC plan representative on the applicant’s behalf. Once NYIA has it, the agency contacts the applicant to schedule the two assessment appointments. If you are exempt or excluded from managed long-term care and not yet enrolled in an MLTC plan, you can apply through your local Department of Social Services instead, but NYIA still has to conduct the assessment before services are authorized.
There is also a separate Information Sharing Consent Form, available at nyia.com/en/consent, that lets NYIA contact your doctors and other providers during the assessment. You can e-sign it online or print a blank copy.
When to Use the Expedited or Immediate Need Form Instead
The standard NYIA Assessment Request Form is not the right form when someone has an urgent need for personal care and no other resources. In that situation, a different form applies: the Expedited/Immediate Need Assessment Request form, submitted electronically through a secure URL rather than on paper.
An LDSS caseworker or a managed care plan requests the secure URL by emailing NYIAHPA@maximus.com. After the form is submitted online, the LDSS or plan places a three-way call with the applicant and the NYIA Operational Support Unit (OSU) at 1-855-665-6942. On that call, the OSU coordinator confirms receipt of the form and schedules both the Community Health Assessment and the clinical appointment within six calendar days.
The expedited path requires two supporting documents that the LDSS or plan must already have in hand before making the referral:
- DOH-5786, the Attestation of Immediate Need, signed by the applicant
- DOH-5779, the Practitioner Statement of Need, completed and signed by the applicant’s physician, nurse practitioner, or physician assistant
The DOH-5786 requires the applicant to attest that they need immediate PCS or CDPAS, that no informal caregivers are available and willing to help, that no home care agency is currently providing services, that adaptive equipment cannot meet their needs, and that no third-party insurance or Medicare is available to cover the care. The DOH-5779 is a one-page certification from the practitioner confirming direct knowledge of the applicant’s condition and the need for services.
If an applicant enrolled in a managed care plan calls NYIA directly asking for an expedited assessment, NYIA will direct them to call back together with a plan representative. The plan has to be part of the referral.
The LDSS has no more than 12 calendar days from receiving the required documents (and a completed Medicaid application, if the person does not already have Medicaid) to refer the individual to NYIA, review the assessment outcome, develop a plan of care, and authorize services.
What Happens After You Submit
Once NYIA has the request, the applicant goes through a two-part evaluation. A registered nurse conducts the Community Health Assessment (CHA) using the UAS-NY, the state’s standard tool for evaluating community-based long-term care needs. A separate clinician from NYIA’s Independent Practitioner Panel — someone with no prior relationship to the applicant — conducts the clinical exam.
Within two to three business days after both appointments are finalized, NYIA mails an Outcome Notice to the applicant and, if applicable, the authorized representative. The results are also posted in the UAS-NY application for the LDSS or managed care plan to review.
The Outcome Notice says whether the applicant has been found eligible for MLTC enrollment or home care services. It does not set the number of authorized hours; that comes later, when the LDSS or managed care plan develops the Plan of Care. A completed CHA is valid for up to 12 months, though a new assessment can be triggered sooner by a change in medical condition, release from institutional care, or a reassessment request.
If the Outcome Notice denies eligibility, you have the right to request a Fair Hearing. You can email NYIAPfairhearings@maximus.com to request the evidence packet NYIA relied on in reaching its determination, which is worth reviewing before the hearing.
Where to Get Help
For general questions about the NYIA program, email independent.assessor@health.ny.gov. For expedited or immediate need requests, the NYIA Operational Support Unit can be reached at 1-855-665-6942. Managed care plans and LDSS offices that need the secure URL for the expedited request form should email NYIAHPA@maximus.com.