Download the official New York Independent Assessor (NYIA) Assessment Request Form and learn how to request an evaluation for Managed Long Term Care (MLTC) services. Need help? Our coordinators walk you through the entire process — free.
Official NYS form · Rev. 05/22 · Free download
The NYIA Assessment Request Form is used by Medicaid health plan members in New York who need community based long term services and supports (CBLTSS) that are not covered by their current plan. Submitting this form requests an assessment from the New York Independent Assessor (NYIA) — the first step toward joining a Managed Long Term Care (MLTC) plan that covers services like home care, social day care, and home-delivered meals.
Your current Medicaid health plan and the MLTC plan you want to join.
Name, date of birth, Medicaid CIN, contact information, and authorized representative details if someone is completing the form on your behalf.
Your signature confirming you understand the MLTC transfer process and authorize your health care provider to share relevant medical information.
Must be completed by a physician, nurse practitioner, or physician assistant confirming the services you need — such as social and environmental supports, home-delivered meals, or social day care.
Completed by the representative of the MLTC plan submitting the form on your behalf.
Once your form is submitted, the New York Independent Assessor will contact you to schedule your assessment. The assessment determines your eligibility to join an MLTC plan. After approval, you can begin receiving covered home care services — including the personal care and skilled nursing services we provide.
The NYIA and MLTC enrollment process can be overwhelming. Our care coordinators help NYC families navigate it every day — explaining your options, helping you gather documents, and following up on your assessment. There's no charge and no obligation.
(347) 308-5339Disclaimer: The NYIA Assessment Request Form is an official New York State document provided here for your convenience. New York's Comprehensive Home Care Agency is not affiliated with the New York Independent Assessor or New York Medicaid Choice. For official information, visit nyia.com or call NYIA directly.
Our coordinators guide you through every step — at no cost.
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