How to Enroll. All rights reserved. The Fidelis Care Pharmacy Team is requesting your feedback! Questions or comments: chplus@health.ny.gov . On this bonus episode of 20-Minute Health Talk, host Sandra Linday, RN, speaks with two pediatricians using the New York State program, a collaboration between the New York State Office of Mental Health (OMH) and seven top universities and hospitals across the state, led by University at Buffalo (UB). The Category Search is arranged by topic. Log in, register for an account, pay your bill, print ID cards, and more. FidelisCare offers four different income-based "tiers" of the Essential Plan. Provider manuals, tip sheets, importantforms, and applications. Coverage of Vaccines for Medicaid and Child Health Plus Members(PDF), Guide to Billing for Obstetrical Providers(PDF), Special Needs Model of Care Training(PDF), Continuity of Care Responsibilities(PDF), Columbia Suicide Severity Rating Scale(PDF), Generalized Anxiety Disorder 7 ItemGAD 7 Scale(PDF), Access and Availability Standards Tip Sheet (PDF), Adult Day Health Care Provider Tip Sheet (PDF), AIDS Adult Day Health Care Provider Tip Sheet (PDF), BH-HCBS Plan of Care Workflow for HealthierLife (PDF), Consumer Direct Personal Assistance Services Tip Sheet (PDF), Home and Community Based Services (HCBS) Billing and Coding Tip Sheet (PDF), Importance of Chlamydia Screening Tip Sheet (PDF), Interactive Voice Response Application for Checking Claim Status Tip Sheet (PDF), MedicaidandCHP Provider Tip Sheet (PDF), Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims Tip Sheet (PDF), Medicare Advantage & Dual Advantage Tip Sheet (PDF), Personal Care Services (PCS) Tip Sheet (PDF), Provider Portal User Guide - Online Authorizations Tip Sheet (PDF), Request for Authorization Fax Lines Reference Tool Tip Sheet (PDF), Transportation Services (Non-Emergency) - Livery-Taxi/Ambulette/Ambulance Tip Sheet (PDF), Transportation Services (Non-Emergency) - Out of County Approval Request Tip Sheet (PDF), BabyCare Prenatal Encounter Form 2018 (PDF), BabyCare Postpartum Encounter Form 2018 (PDF), Personal Care Benefit Physician's order form (Outside of New York City) DOH 4359 (2010) (PDF), Personal Care Benefit Physician's request form (New York City) Form M-11q (12/2014) (PDF), Provider Transportation Application For Members to request non-emergency livery, ambulette, & ambulance transportation (PDF), Out-of-Area Transportation Application for Members to request non-emergency transportation service to non-local providers (PDF), Podiatry Services Treatment Request Form (PDF), Durable Medical Equipment Request Form (PDF), OB Ultrasound Authorization Request Form (PDF), Preventive Care Assessment Form for Children and Adolescents (PDF). Fidelis Care: 1-888-343-3547; MVP Health Plan, Inc.: 1-800-852-7826; UnitedHealthcare Community Plan: 1-800-493-4647; Allegany: child health plus - Health Plan and Assistance . The Children's Health and Behavioral Health Program begins in phases. Find a Doctor; Get a Quote for a Plan; Help Me Find a Plan; . To create a secure online member account, visit. Fidelis Cares Childrens Health and Behavioral Health Program is for qualifying Medicaid Managed Care members under age 21who meet medical necessity criteria. By clicking this link, you will leave the Fidelis Care website. Authorized Generic vs. "Typical" Generic: What is the Difference? Dermatologist. Child Health Plus At a Glance CONTACT US: nystateofhealth.ny.gov | 1-855-355-5777 or TTY 1-800-662-1220 NY State of Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. We are proud to be your healthcare partner and want tohelp youaccess essential health benefits and services to keep you ashealthy as possible. A higher education level was a protective factor for total exposure time. Pay your monthly premium and set up auto-pay; . With 24/7 access to your Fidelis Care account, you can pay your monthly premium,request and print new ID cards, and access your plan documents. Tel:
Office visits are $0, $15 for a PCP and$25 for a specialist. Certain durable medical equipment such as nebulizers, wheelchairs, hospital beds, etc are available under the Fidelis Care medical benefit for these members. That's about $1150 a week for a three-person family, about $1387 a week for a family of four. For a complete list of covered items, please refer to section 4.4, 4.5, 4.6, and 4.7 in The New York DMEPOS Manual. New York State-sponsored program that provides quality, *** Child Health Plus covers prescription or non-prescription drugs listed in the formulary with no cost-sharing as long as they are ordered by a provider wi, FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Contact a Representative Today to Determine Your Eligibility for Child Health Plus, 24/7 telemedicine benefit through Babylon Health, Transparency in Coverage Machine Readable Files, Medical, dental, and vision coverage for kids up to 19*, Checkups, well child visits, and sick visits, Free or low-cost monthly premium, depending on income (no limit), Occupational, speech, and physical therapy**. Frequently Asked Questions (FAQ) Use the location bar above to find providers of these services in your area.See the FAQs to learn how to save and organize your results. Members will need to renew their health insurance to keep their coverage without interruption. High snus exposure duration was associated with an earlier starting age, a longer history of use and a careless attitude to its health hazards. Log into your account, view patient information, and more. Authorization to Use and Disclose Health Information (PDF), Revocation of Authorization to Use and/or Disclose Health Information(PDF), General Statement of Member Rights and Responsibilities (PDF). Navigation menu. Areas Served: Broome. Children may qualify for Child Health Plus if they are younger than 19, a New York state resident, do not already have health insurance and are not eligible for coverage under the public employees' state health benefits plan, and not eligible for Children's Medicaid. You can review, select, or change your PCP from your. * Always check with your Primary Care Provider to find out if a referral is required for any additional health services you might need. The Privacy Rule applies to all forms of your protected health information, whether electronic, written, or oral. If the family's income is more than 4 . Fidelis Care - Medicaid Managed Care provides personal care from one's own doctor, hospital and emergency care, prenatal care, eye exams, eye glasses and more. Information to help you and your provider better manage your health. The $9 family premium contribution for children enrolled in the Child Health Plus program (households with income between 160% and 222% of the federal poverty level) has been eliminated for enrollment effective October 1, 2022. To initiate a Prior Authorization, please use the following form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf, Medication Request Form for Medicaid, HARP, CHP, Essential Plans, and Qualified Health Plans(PDF), Pharmacy Electronic Prior Authorizations Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) planswill receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. ), FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Transparency in Coverage Machine Readable Files. Visit our Davis VisionResource Page(by clicking on this link, you will leave the Fidelis Care website) for information on getting started. COVID-19 Vaccine . Call 1-888-FIDELIS (1-888-343-3547), TTY: 711. No copays for covered services and no monthly premium if qualified. HUS is the biggest health care provider. tool. Log into your account, view patient information, and more. To initiate a Prior Authorization, please use the following form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf, Medicare Prescription Drug Denial Request for Redetermination(PDF), MedicareElectronic Drug Coverage Determination Form(Web Resource), Medicare Prescription Drug DenialRequest forRedetermination Online Form(Web Resource), Acaria Health Specialty Medication Referral Form (PDF), CVS Caremark Specialty Pharmacy Fax Enrollment Form(PDF), Coram Infusion Services - Pegfilgrastim Products Enrollment Form (PDF), Coram Infusion Services - Infliximab Enrollment Form(PDF). Duchenne Muscular Dystrophy (DMD) Physician Administered Drug Policies, Genentech Physician Administered Drug Policies, Oncology Statement - American Society of Clinical: Biosimilars in Oncology, COVID-19 At-Home Antigen Test Covered Products, COVID-19 Oral Antivirals Pharmacy Billing Guide, COVID-19 Vaccine Counseling Medical Billing Guide for NY Medicaid, COVID-19 Vaccine Pharmacy Billing Guide: Booster Doses, COVID-19 Vaccine Pharmacy Billing Guide: Additional Doses for Immunocompromised, Opioid Prior Authorization Form(PDF) Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) planswill receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. Fidelis Care can help. Log in or register to makepayments, print ID cards, choose or change a PCP, and much more. Your child, covered. In addition, Healthgrades placed the medical center within the top 1% of hospitals in the nation for clinical care . Our expertise is internationally recognized and accredited. Contact a Representative Today to Determine Your Eligibility for Child Health Plus. Your Subscriber Contract provides a full description of the services included in your benefitpackage, as well as cost information for those services. 24/7 Telemedicine Visits . Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. ), (By clicking this link, you will leave the Fidelis Care website. Search for a medical professional, service, or facility in the Fidelis Care Network. Individuals/Families. For a 2-person household You can make up to: Call the NY State Medicaid Helpline at 1-855-648-1909 (TTY: 1-800-662-1220) or email NYRx@health.ny.gov. For " Special Circumstance " Questions for Child-Related Health Insurance. . You can complete this brief survey on the Member Portal. By clicking on these links, you will leave the Fidelis Care website. FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Important Updates Regarding Coronavirus COVID-19, Transparency in Coverage Machine Readable Files, Preventive care and chronic disease management. Check out our additional info panels below for more educational information. Log in, register for an account, pay your bill, print ID cards, and more. Resources that provide survival level services including food, housing, material goods, transportati Resources that provide medical and/or supportive services for people with disabilities or behavioral Resources that help meet financial needs by helping people find and sustain employment, enroll in pu Resources that help people access social groups and activities in their communities including commun Resources that protect consumer rights, help with legal services and provide information on public s A New York State sponsored health insurance program. To review Fidelis Care's best practice guidelines for healthy vision, click HERE. Visit fideliscare.org/costcalculator to find a treatment costcalculator, providing you with estimates that cover other conditions and services (for Qualified Health Plans and Essential Plan members;after January 1, 2023, if you have any questions about this information, please call Member Services at 1-888-343-3547). Fidelis Care Child Health Plus: (New York State-sponsored health insurance) A New York State sponsored health insurance program. The Essential Plan is for New Yorkers who do not qualify for Medicaid or Child Health Plus, but still need access to high quality health care. The Child Health Plus At a Glance Card has been updated to reflect this change. Soon, Mr. Ackies Jr. was playing with and against his entire . Learn how health insurance helpsmanage expenses,and prepare for the unexpected. 1-855-355-5777. Log in, register for an account, pay your bill, print ID cards, and more. News you can use to live healthier and get the most out of your health insurance! New York State, Telephone:
With two campuses and 668 beds, Staten Island University Hospital is the borough's major teaching hospital and one of the New York metropolitan area's largest. By clicking on these links, you will leave the Fidelis Care website. Authorization Grids for Medicare, Medicaid, Child Health Plus, andNY State of Health Marketplace plans. Please click on thislinkto share your feedback. Your costs will be higher if you receive care out of network. Once you know the health coverage you qualify for, there are three ways you can enroll: Call 1-888-FIDELIS (1-888-343-3547), TTY: 711; Find a Fidelis Care office near you. Both Children's Medicaid and Child Health Plus are available through dozens of providers throughout the state. For a Northwell ambulance, call (833) 259-2367. Please use the Find-A-Doc Tool to locate a Durable Medical Equipment supplier. Please note, members will continue to receive their medical benefits through Fidelis Care. The Essential Plan offers access toessential health benefits, such as: Essential Plan members are also eligible for Fidelis Care's Fitness Reimbursement Program. The cost examples are estimates only,and serve as a guide for how your particular plan might cover different conditions; not theexact dollar amount you will pay. NY Connects is your trusted place to go for free, objective information about long term services and supports in New York State for people of all ages or with any type of disability. After 155 years, we continue to earn public and peer recognition for quality care. Please print, copy, link to and share. (By clicking this link, you will leave the Fidelis Care website. request and print new ID cards, and access your plan documents. By clicking on these links, you will leave the Fidelis Care website. Families with somewhat higher incomes pay a monthly premium of $15, $30, $45, or $60 per child per month, depending on their income and family size. Log into your account, view patient information, and more. Visit www.nystateofhealth.ny.gov and click on "Get Started." Log in, register for an account, pay your bill, print ID cards, and more. We're here to help. Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) planswill receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. The Fidelis Care Pharmacy Team is requesting your feedback! Search for a medical professional, service, or facility in the Fidelis Care Network. 2023 Wellcare Fidelis Assist and Wellcare Fidelis No Premium Medicare Members: . We are responsible for organizing specialized healthcare in the Uusimaa region. Fidelis Care provides quality, affordable health insurance coverage to more than 1.7 million people of all ages and at all stages of life in New York State. You can sign up today! The Centers for Disease Control Oral Health Page. 2023 Comprehensive Formulary | Wellcare Fidelis Assist (Plan 002) Formulary Search Tool (Plan 002) Notice of Change (Plan 002) The Pediatric Surgical Operating Complex consists of eight 600-square-foot, child-friendly operating suites. To review Fidelis Care's best practice guidelines for healthy vision, click, To learn more about HIPAA and your privacy rights, visit the, FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, U.S. Department of Health and Human Services, Authorization to Use and Disclose Health Information, Revocation of Authorization to Use and/or Disclose Health Information, General Statement of Member Rights and Responsibilities, Transparency in Coverage Machine Readable Files, Information about the transition of the pharmacy benefit from Fidelis Care Medicaid to NYRx, the Medicaid Pharmacy Program can be found, General information about NYRx, the Medicaid Pharmacy Program can be found, Do you have questions or need help? Only the monthly premiums vary based on income, and offer FREE Insurance, if qualified. At a Glance Cards - English. Overview. Find a Fidelis Care office near you . No matter how much income you make. Once you know the health coverage you qualify for, you can: Tell us more about yourself to find qualifying plans and estimate costs. For more information regarding the pharmacy benefit transition, please visit NYRx, the Medicaid Pharmacy Program. Monday - Friday 8am-8pm The majority of Fidelis Care health plans include some form of dental coverage. For members with vision coverage, your benefits are covered through Davis Vision. Wellcare By Fidelis Care Medicare and Dual Advantage Plans. Essential Plan members are also eligible for Fidelis Care's. Log into your account, view patient information, and more. Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fully Integrated Duals Advantage (FIDA), Fidelis Care at Home (MLTC), and HealthierLife (HARP) (PDF) Personal Care Services (PDF) Qualified Health Plans and Essential Plans (PDF) Transportation (PDF) 6 mi. The Children's Health and Behavioral Health Program supports children and families by helping to remove quality of life roadblocks caused by mental illness, substance use, and medically fragile conditions in childhood . 2021 NY State of Health. Fidelis Care is here to help you live your healthiest life and make informed health insurance decisions: FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, medically fragile conditions in childhood, Transparency in Coverage Machine Readable Files, Help with getting a child and family assessed and started with counseling or psychotherapy, Help with restoring a childs functioning at school, home, or in the community with hands-on tasks, Support for families and caregivers of a child with social, emotional, medical, developmental, or behavioral challenges, Specialized services delivered in the home and community to enhance a childs functional health or behavioral health care issue. Cohen Children's Medical Center today announced the opening of the Pediatric Surgical Operating Complex, a $110 million, 24,000-square-foot, state-of-the-art home for pediatric surgery that greatly enhances the capabilities of New York . For members with dental coverage, yourbenefits are covered through DentaQuest. Read the latest member newsletter and browse the archives. Medicaid Managed Care offers comprehensive coverage with no copays for covered services and no monthly premium for those who qualify. If it has been over a year since you have seen a dentist, we recommend that you make an appointment to see one as soon as possible. In an effort to identify opportunities for improvement, we are asking all providers to participate in a short survey. Log in, register for an account, pay your bill, print ID cards, and more. Log in, register for an account, pay your bill, print ID cards, and more. Prior authorization is needed for certain services, and if you need to see an out of network provider. for more information about new child and family treatment supportservices offered through New York State Medicaid. Speak with a customer service professional by phone. 1-800-342-9871. (by clicking on this link, you will leave the Fidelis Care website) for more information on getting started, and preventive dental care best practices. HUS is the largest provider of specialized healthcare in Finland, with 27,000 top professionals treating nearly 700,000 patients every year. The Keyword Search helps you find long term services and supports in your area. *** Child Health Plus covers prescription or non-prescription drugs listed in the formulary with no cost-sharing as long as they are ordered by a provider within the Fidelis Care network. To request a paper copy, call Fidelis Care at 1-888-FIDELIS (1-888-343-3547); TTY: 711. Child Health Plus, Essential Plan, and HealthierLife (HARP) plans must renew their health coverage. * Always check with your Primary Care Provider to find out if a referral is . How to Enroll. Northwell Health STARS Rehabilitation and Pickleball Plus offer injury-prevention tips. Read the CHP Subscriber Contract for information about pharmacy and utilization management procedures, specific benefit inclusions and exclusions, and to learn how to get care using our provider network. As part of your plan, you have access to aPreferred Pharmacy Networkwith lower costs. We're also Staten Island's largest employer with 7,000 positions. (by clicking on this link, you will leave the Fidelis Care website) for information on getting started. Once youknow the health coverage you qualify for, you can: Tell us more about yourself to find qualifying plans and estimate costs. Child Health Plus (CHPlus) is aNew York State-sponsored program that provides qualityhealth insurancefor kids under age 19. Fidelis Care - Medicaid Managed Care provides personal care from one's own doctor, hospital and emergency care, prenatal care, eye exams, eye glasses and more. During the COVID-19 public health emergency, NY State of Health is automatically renewing . Step 2: Fill Out Your Health Risk Assessment, Fidelis Care is committed to ensuring you have access to the preventive care and screenings you need to stay healthy. Enroll Online v ia NY State of Health. If you are enrolled in a Medicaid, Child Health Plus or a qualified health plan, you may be able to continue the same coverage or amount of financial assistance during the appeal process. Log into your account, view patient information, and more. FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Important Updates Regarding Coronavirus COVID-19, Transparency in Coverage Machine Readable Files. You can access your Summary of Benefits and Coverage,Subscriber Contract, Formulary,and other important plan documentsby logging into the MemberPortal. TheSummary of Benefits and Coverageoutlines some of your plans key benefits, and explains how much they couldcost. The Essential Plan is for individuals who meet certain income requirements. information about medication(s) covered under NYRx. Please click on this, FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf, Medication Request Form for Medicaid, HARP, CHP, Essential Plans, and Qualified Health Plans, Medicare Prescription Drug Denial Request for Redetermination, MedicareElectronic Drug Coverage Determination Form, Medicare Prescription Drug DenialRequest forRedetermination Online Form, Acaria Health Specialty Medication Referral Form, CVS Caremark Specialty Pharmacy Fax Enrollment Form, Coram Infusion Services - Pegfilgrastim Products Enrollment Form, Coram Infusion Services - Infliximab Enrollment Form, Care Management Services for Extra Member Support, Oncology Services -Medicaid Managed Care and HealthierLife, Oncology Services -Essential Plan and Metal-Level Products/QHP, Oncology Services -Medicare | Wellcare by Fidelis Care, Medicaid Pharmacy List of Reimbursable Drugs, 2023 PA Criteria | Wellcare Fidelis Assist (Plan 002), 2023 PA Criteria | Wellcare Fidelis No Premium (Plan 004), 2023 PA Criteria | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008), 2023 ST Criteria | Wellcare Fidelis Assist (Plan 002), 2023 ST Criteria | Wellcare Fidelis No Premium (Plan 004), 2023 ST Criteria | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008), 2023 Covered Diabetes Meters and Testing Supplies, Transparency in Coverage Machine Readable Files. This is the official informational website of NY State of Health The Official Health Plan Marketplace. By clicking on these links, you will leave the Fidelis Care website. Do you have questions or need help? Call 1-888-FIDELIS (1-888-343-3547), TTY: 711; Find a Fidelis Care office near you.Make an appointment, or walk right in during regular business hours! Authorization Grids for Medicare, Medicaid, CHP, andNYSOHMarketplace. (By clicking this link, you will leave the Fidelis Care website.). As a university hospital, we continuously develop and evaluate our treatment methods and activities. Provider: Fidelis Care. If you need help finding a doctor or choosing your PCP, call Member Services at 1-888-FIDELIS (1-888-343-3547); TTY: 711. tool can also provide The $9 family premium contribution for children enrolled in the Child Health Plus program (households with . Please print, copy, link to and share. Costs vary between tiers depending on your eligibility: Enroll at any time. There is no deductible for any of the plans. Conveniently chat online with one of our representatives. In fact, U.S. News ranked Lenox Hill among the top 50 hospitals in the nation for gynecology for 2021-22 and New York Magazine listed 37 Lenox Hill physicians specializing in obstetrics and gynecology in the latest edition of its annual "New York's Best Doctors" issue. For more information on using Amazon Pharmacy, please visitwww.amazon.com/pharmacyor call 855-745-5725. Conveniently chat online with one of our representatives. It is important for everyone over the age of 1 to visit the dentist at least one time every year in order to help keep your teeth and gums healthy. Welcome to treatment at HUS! Find a Fidelis Care Community Office near you. American Dental Association. Formularies, utilization management programs, general pharmacy updates, and specialty drug programs. 2023 Wellcare Fidelis Assist and Wellcare Fidelis No Premium Medicare Members: As part of your plan, you have access to a Preferred Pharmacy Network with lower costs. To create a secure online member account, visit members.fideliscare.org and click Register.. (888) 321-DOCS. For larger families, the monthly fee is capped at three children. Its also great for people who cant get health coverage through their employer. No need to wait for open enrollment: You can enroll in Medicaid Managed Care year-round. News you can use to live healthier and get the most out of your health insurance! Child Health Plus covers prescription or non-prescription drugs listed in the formulary with no cost-sharing as long as they are ordered by a provider within the Fidelis Care network. Your Subscriber Contract provides a full description of the services included in your benefitpackage, as well as cost information for those services. Suicide Prevention Lifelineis available at 1-800-273-8255 and offers free and confidential crisis support available 24/7 to anyone at any time. Log into your account, view patient information, and more. If you already have a PCP who is in the Fidelis Care network, then that provider should have been automatically assigned as your PCP. FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Important Updates Regarding Coronavirus COVID-19, Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fully Integrated Duals Advantage (FIDA), Fidelis Care at Home (MLTC), and HealthierLife (HARP), Qualified Health Plansand Essential Plans, Coverage of Vaccines for Medicaid and Child Health Plus Members, Guide to Billing for Obstetrical Providers, Generalized Anxiety Disorder 7 ItemGAD 7 Scale, Access and Availability Standards Tip Sheet, AIDS Adult Day Health Care Provider Tip Sheet, BH-HCBS Plan of Care Workflow for HealthierLife, Consumer Direct Personal Assistance Services Tip Sheet, Home and Community Based Services (HCBS) Billing and Coding Tip Sheet, Importance of Chlamydia Screening Tip Sheet, Interactive Voice Response Application for Checking Claim Status Tip Sheet, Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims Tip Sheet, Medicare Advantage & Dual Advantage Tip Sheet, Provider Portal User Guide - Online Authorizations Tip Sheet, Request for Authorization Fax Lines Reference Tool Tip Sheet, Transportation Services (Non-Emergency) - Livery-Taxi/Ambulette/Ambulance Tip Sheet, Transportation Services (Non-Emergency) - Out of County Approval Request Tip Sheet, Personal Care Benefit Physician's order form (Outside of New York City) DOH 4359 (2010), Personal Care Benefit Physician's request form (New York City) Form M-11q (12/2014, Provider Transportation Application For Members to request non-emergency livery, ambulette, & ambulance transportation, Out-of-Area Transportation Application for Members to request non-emergency transportation service to non-local providers, Speech, Physical, or Occupational Therapy Treatment Request Form, Preventive Care Assessment Form for Children and Adolescents, Transparency in Coverage Machine Readable Files.