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Business Link Friends & Family Application
HIPAA
Compliance
1
Your Name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
This field is required.
Area Code
Phone Number
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3
Your E-mail Address
example@example.com
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4
Do you live in the State of New York?
*
This field is required.
YES
NO
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5
Are you currently providing care to a family member or friend?
*
This field is required.
YES
NO
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6
Is the person you are caring for a Medicaid recipient?
*
This field is required.
For example: This person has a Benefit Card
YES
NO
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7
Do you have the Medicaid Number of the person you are looking to care for?
*
This field is required.
YES
NO
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8
Medicaid Number
*
This field is required.
This can be found on the Benefit Card
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9
Who do you plan on providing home care service to?
*
This field is required.
Parent
Grandparent
Sibling
Friend
Child
Other
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10
Name of the person you would like to care for
First Name
Last Name
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11
Image Field
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