DOH Deadline for CDPAP Fiscal Intermediary Application
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Lead FI Collaborator Status Application

ATTN: CDPAP / CDPAS

 

Apply now to be included as a collaborator in the RFO for one or more of our Lead FI agencies.

Lead FI Collaborator Status Application

 

Any information you provide will be kept strictly confidential, and will not be shared with any third parties outside of Condor Healthcare Consultants. If you are selected for consideration we will notify you directly.

Company or Organization Name*

Company Street Address (Main Office)*

Company City, State, Zip Code*

Company Phone Number (Main)*

Company Website

Was your organization established as a Fiscal Intermediary prior to January 1, 2012 (Yes or No)*
YesNo

Are you currently providing services for CDPAP individuals? (Yes or No)*
YesNo

Approximately how many CDPAP / CDPAS clients are you currently serving?*

List the NYS counties you serve - or propose to serve - along with the estimated # of CDPAP/CDPAS members served in each county (separate counties by line breaks)*

Languages Served*

Use the text area below to tell us anything important we should know about your company as well as why you should be selected for consideration*

Contact Person for Application (Full Name)*

Title of Contact Person*

Contact Email*

Direct Phone Number*

Comments or Questions