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Agency Information
Name
Address 1
Address 2
City
State
Zip Code
Agency Contacts
Contacts (Name, Title, Phone Number and Email address)
Programs
Please select the programs / services your agency provides
OPWDD - Traditional
Article 16 Clinic
Community Habilitation
Day Habilitation
Intermediate Care Facility
IRA - Supervised
IRA - Supported
Pathway to Employment
Plan of Care Support Services
Prevocational Services
Respite
Supported Employment
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
OPWDD - Self Directed
Community Habilitation
Community Transition Services
Family Education and Training
Fiscal Intermediary
Individual Directed Goods and Services
Live In Caregiver
Respite
Support Broker Services
Supported Employment
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
Other Programs
Article 28 Clinic (Primary Care)
Article 31 Clinic (OMH)
Article 32 Clinic (OASAS)
CANS NY Assessment (Health Homes)
Care Management (Health Homes)
Caregiver Family Supports and Services (CFTSS/Children HCBS)
Community Habilitation (CFTSS/Children HCBS)
Community Psychiatric Support and Treatment (CFTSS/Children HCBS)
Community Residence (OMH)
Community Self-Advocacy Training and Supports (CFTSS/Children HCBS)
Community Support and Treatment (Adult HCBS)
Crisis Intervention (CFTSS/Children HCBS)
Day Habilitation (CFTSS/Children HCBS)
Education Support Services (Adult HCBS)
Family Peer Supports (CFTSS/Children HCBS)
Family Support and Training (Adult HCBS)
Foster Care (OCFS)
Habilitation Services (Adult HCBS)
HARP Assessment (Adult HCBS)
Medication Assisted Treatment
Opioid Treatment Program
Other Licensed Practitioners (CFTSS/Children HCBS)
Peer Support Services (Adult HCBS)
Personalized Recovery Oriented Services (OMH)
Plan of Care Development (Adult HCBS)
Prevocational Services (Adult HCBS)
Prevocational Services (CFTSS/Children HCBS)
Psychosocial Rehabilitation (Adult HCBS)
Psychosocial Rehabilitation (CFTSS/Children HCBS)
Respite (Adult HCBS)
Respite (CFTSS/Children HCBS)
Staff Transportation (Adult HCBS)
State Designated Entity Assessment (Adult HCBS)
Supported Employment (Adult HCBS)
Supported Employment (CFTSS/Children HCBS)
TBI Service Coordination
Transitional Employment (Adult HCBS)
Youth Peer Support and Training (CFTSS/Children HCBS)
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
Additional Information
What is your agency's approximate annual revenue?
Which EMR / EHR system (if any) does your agency currently use?
Which EVV system (if any) does your agency use?
Are you also interested in a quote to outsource the billing process?
Yes
No
Is there any other information you would like to share with us?
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