CDPAP Program | NY | Special Touch Home Care

Request Type

Service/Program Being Requested*

Which service is the prospect interested in receiving with Special Touch?

HHA Services
CDPAP Program

Type of Request*

Is prospect already receiving services (HHA or CDPAP) and only looking to switch agencies? Or is this an entirely brand new request for the prospect?

New Request
Agency to Agency Transfer

Agency to Agency Transfer

What Program/Insurance is he/she receiving services through?*

Who is the prospect's primary program contact?*

What is the prospect's primary program contact's direct phone number?*

What is the name of the current agency?

What type of service is the prospect currently receiving?*

Comments or additional notes*

When you submit this form an Account Manager (AM) will be assigned to process the prospect for services. Provide as much detail as possible on any preliminary conversations you’ve had so the AM can do their job effectively.

Reason for Home Care Request

This is where you indicate why the prospect is requesting Home Health Aide services with Special Touch. Do they suffer from hypertension, diabetes, dementia, high cholesterol, etc?

Prospect Diagnoses 1*

Prospect Diagnoses 2

Ambulatory Status*

MENTAL HEALTH STATUS*

Comments or additional notes*

When you submit this form an Account Manager (AM) will be assigned to process the prospect for services. Provide as much detail as possible on any preliminary conversations you’ve had so the AM can do their job effectively.

Physician Information

The physician that you enter here does not need to be the prospect’s primary care physician. It can be any physician that the prospect has an active and current relationship with.

MD Name

Address

Street Address Address Line 2 City ZIP Code

MD Tel#

MD Fax#

Reason for CDPAP Request

This is where you indicate why the prospect is requesting CDPAP with Special Touch. Do they suffer from hypertension, diabetes, dementia, arthritis, etc?

CDPAP Prospect Diagnoses 1*

CDPAP Prospect Diagnoses 2

CDPAP Ambulatory Status*

CDPAP Mental Health Status*

Physician Information

The physician that you enter here does not need to be the prospect’s primary care physician. It can be any physician that the prospect has an active and current relationship with.

MD Name

MD Address

MD Street MD Address line 2 MD City MD MD Zip

MD Tel#

MD Fax#

* means the field is required.

We are hiring PCA’s and HHA’s in all the boroughs.

STHC Office Staff Referral Form

STHC Office Staff Referral Form

Step 1 of 6

Office Staff (Referrer) Information

Prospect's Demographics

Primary Point of Contact Information

Insurance Information

Request Type

Agency to Agency Transfer

Reason for Home Care Request

Physician Information

Reason for CDPAP Request

Physician Information

The Final Details