Provided below are all the necessary forms for CDPAP Consumers and Personal Assistants (PA) to enroll in services and apply for employment. Please print out and complete the forms following the order suggested below.
If you need help with anything, please call us at (718) 486-5550.
Please print out the complete CDPAP Employment Application to begin the process of signing up to be the Personal Assistant (PA):
Download: CDPAP Employment Application (for PA)
The following are individual forms with descriptions of each form. Many of these forms are in the CDPAP Employment Application.
- No Conflict Attestation
- Please Start Here. This form is very important!
- This form verifies that the person applying qualifies to act as consumer’s PA. Once this form is approved, the applicant can proceed to fill out the CDPAP application.
- CDPAP Employment Application (for PA)
- Please provide all necessary information to confirm eligibility requirements.
- Read, sign, and date all agreements.
- Work Availability (for PA)
- What days and hours can the PA work? What locations can the PA work? Any specific work preferences?
- W-4 Form (for PA)
- This is used to withhold the proper amount of federal income tax from your paycheck.
- I-9 Form (for PA)
- This is used to verify a PA’s identity and to establish that the worker is eligible to accept employment in the United States.
- Wage Letter Pay Rate Form (for PA)
- This confirms that you know and agree to your pay rate.
- MUST get verified by Edison Home Health Care for approval.
- DOH Form – Physician’s Order (for Consumer)
- Your Doctor must confirm that you, the consumer, are authorized to receive services.
- This form is 100% Mandatory – Your doctor MUST fill out this form and either mail or fax it back to Edison Home Health Care in order to get approved.
- Habituation Statement (for PA)
- Form may NOT be more than 8 months old.
- If you DO NOT have medical forms filled out, please proceed to item 2.
- If your medical forms have already been filled out by your doctor prior to coming to Edison, you ONLY need THIS form and NOT forms 2,3, and 4.
- Pre-Employment Physical (for PA)
- This MUST be signed and completed by your Doctor.
- Tuberculosis (TB) Questionnaire (for PA)
- Are you PPD Positive? If the answer is yes, your doctor must fill out this form.
- If you are negative, skip this form.
- Flu Vaccine Declination (for PA)
- Please only fill out this form if you, the PA, want to decline the flu vaccine shot. This form MUST be filled out between the months of October – March.
- The PA MUST present proof of shot to get this form approved.
- If the PA is NOT getting a flu shot, please skip this form.
Changing Health Plans
- PCP Transfer Form (for Consumer)
- Patient needs this form filled out by their Doctor to transfer from their current plan to any other type of health care plan.
- CDPAP Welcome Package (for Consumer)
- General information for the consumer including rules and guidelines for CDPAP. Take a look to learn more about your rights as a consumer and what type of coverage is included in CDPAP.
- CDPAP Handbook (for PA)
- General information for the PA including Rules and Guidelines for CDPAP. Take a look to learn more about how to succeed as a PA.