Fill out the form below to check eligibility and start the Medicaid approval process for Personal Care Aide (PCA) services.

If the patient can’t complete the form due to age or disability, a caregiver or trusted person can submit it for them.

🟦 Don’t have a caregiver yet?
No problem — just complete the patient section, and our team will guide you from there.

Basic Requirements

The Patient must:

  1. Need help with daily activities due to disability or a long-term health condition
  2. Have or want to apply for Medicaid
  3. Be 18+ and a New York State resident

Their caregiver must:

  1. Be 18+ and authorized to work in the U.S.
  2. Complete a health check and PCA training (we assist with both)

We respect your privacy. Your information is used only to assess PCA eligibility.

What Happens Next?

  1. We’ll review your form quickly
  2. A team member will contact you with the next steps

📞 Need Help?

Call: 718-395-6329
Email: contact@familycaregiverny.com


id number
The Medicaid Client ID Number (CIN) is preferred and can be found on the front of the patient’s NYS EBT card, as shown in the example above. If you cannot locate the CIN, you may use their SSN instead.