Intake and Enrollment Checklist and Information Sheet

Thank you for your interest in Advance Care Alliance (ACA)! In order to proceed with service enrollment for you or your loved one, demographic information and several documents are required. This sheet has been developed as a guide to assist applicants with gathering the appropriate information and make the process as efficient as possible. Please fill out and print the checklist below to include when you mail ACA the required documents.

Intake and Enrollment Checklist

Applicant Information Needed:

  • Name of Applicant;

  • Address of Applicant;

  • Telephone Number;

  • TABS ID Number;

  • Medicaid Number;

  • Parent/Advocate Name;

  • Parent /Advocate Telephone Number.

Documents Needed:

  • Psychological Evaluation (with Full Scale IQ score) – completed within the last 3 years ;

  • Psycho-social Evaluation (with Developmental Milestones) – completed within the last year ;

  • Medical evaluation (signed by a MD) – completed within the last year;

  • Signed consent form – original signature needed ;

  • OPWDD Eligibility Letter;

  • Current Level of Care Eligibility Determination (if applicable).

Please mail the documents mentioned above and this information sheet to the address below:

 Advance Care Alliance of New York 500 7th Avenue, 8th floor

New York, NY 10018 Attention: Intake Department

Kind Regards,

Advance Care Alliance Intake and Benefits Access Team 1-833-692-2269 ext. 447 (Aca.intake@myacany.org)

Please click here for Adult Health Home Patient Information Sharing Consent Forms (over 18)
Please click here for Child Health Home Consent Enrollment Forms (under 18)
Please click here for Child Health Home Information Sharing Consent Forms (under 18)
Please click here for Child Health Home Consent Frequently Asked Questions (under 18)

To have someone from ACA call you, please fill out this short form.