Documents Needed to Apply for the Consumer Directed Personal Assistance Program:
Please click on the link below to download and print out the forms. Upon completion, please contact us by clicking here should you have additional questions.- 1. Consumer Directed Personal Assistance Program application (aka: M13D)
- A patient's family representative, also know as the designated representative, has to complete and sign this form. A backup designated representative also has to complete and sign a statement at the end attesting to his/her responsibility to serve as a backup in case if the designated representative is not available. We have provided a sample here for your reference.
- 2. Medical Request for Home Care
- This form, also know as M11Q, must be completed by your primary care physician. The form is valid for up to thirty days. That means at the time of submission, this form must not be dated over thirty days old.
- 3. Attestation of Immediate Need
- This form is used to demonstrate or certify that you need an expedited processing of your application. In general, completing and submitting this form places your application in a priority manner.
- 4. Authorization for Release of Health Information Pursuant to HIPPA Form
- As the name of the form suggests, this is a privacy release consent form.
- 5. An actual sample form with sample answers from the CDPAP application (M13D)
- Disclaimer: This sample is provided as a reference only. The answer that you provide should be specific and detailed and is tailored to your situation and living arrangement.
Below is a flowchart outlining the steps involved in applying for CDPAP service:
