For families

Patient forms & requirements

Eligibility and the documents you'll need to start home care with us.

To qualify for our care

Every client meets these before services begin. Our intake team helps you get there if you're partway.

New York State resident in our service area (NYC, Long Island, or Westchester).
Enrolled in Medicaid, Medicare, an accepted commercial plan — or eligible for self-pay.
Medicaid number (CIN) ready for intake — no Medicaid yet? Your Social Security number and date of birth are enough to get started.
Doctor's order (M-11Q) or care manager referral on file before services begin.
Completed in-home assessment by an S&A Registered Nurse.
Health care proxy or power of attorney on file if a family member will represent the client.
The exact document package varies by the services you're applying for and whether you already receive services — our intake team gives you a personalized checklist.

Have these ready when our RN visits — speeds up the paperwork.

M-11Q (Medical Request for Home Care)
Medical
NY State Department of Health form your doctor completes to authorize home-care services. Bring or fax to our office before your in-home assessment.
PDF · NY DOH
View form
Medicaid application (NY)
Insurance
If you don't have Medicaid yet, this is the application. Our intake team can help you complete it during your assessment.
NY State Department of Health
View form

Annual updates and ongoing service forms.

Address Change Form
Update
Let us know whenever your home address changes — moving boroughs, moving across town, or any update to where care is delivered. Mail or fax the completed form to your local office and we'll update your care plan and route your caregiver to the new address without interruption.
PDF · S&A Unified Home Care
View form

Speak with our care team today — most callers are matched with a caregiver within a week.

Know someone who needs care? Share our number — our intake team handles referrals right on the call.