New York Medicaid home care forms explained: DOH-4220, 5178A, 4359, 5779, 5786, 5821

In short: most people getting Medicaid home care in New York touch a handful of state forms. DOH-4220 is the Medicaid application. DOH-5178A is its supplement for people 65+ or disabled. DOH-4359 (or HCSP-M11Q) and DOH-5779 are doctor or practitioner forms. DOH-5786 is the Immediate Need attestation. DOH-5821 verifies an Alzheimer's or dementia diagnosis. The table below says who fills each one out and where it goes.

Last checked September 27, 2026, against the forms posted on health.ny.gov. Always download the current version from the state site.

The forms at a glance

Form	What it is	Who fills it out	Where it goes
DOH-4220	Access NY Health Care application: health insurance for older adults, people with disabilities, and certain others	The applicant or a helper	HRA in NYC, or your county Department of Social Services
DOH-5178A	Supplement A to DOH-4220. Required if anyone applying is 65+, blind, disabled, chronically ill, or applying for nursing home care. It asks about resources	The applicant	With the DOH-4220 to HRA or your county
DOH-4359 or HCSP-M11Q	Physician's order for personal care or consumer directed services	A doctor	With an Immediate Need request to the local office. In regular requests, the NYIA clinician writes the order
DOH-5779	Practitioner Statement of Need for personal care or CDPAP, for adults 18+. Shorter than the physician's order	An MD, DO, NP, or PA	To the local office with an Immediate Need request
DOH-5786	Immediate Need informational notice and attestation for personal care or CDPAP	The applicant or representative signs page 3	To the local office (HRA in NYC)
DOH-5821	Alzheimer's disease and dementia diagnosis verification	A provider (MD, DO, NP, or PA completes it; the diagnosing provider must be an MD or DO)	Given to the assessor at the Community Health Assessment
DOH-5139	Disability Questionnaire used by the State Disability Review Unit	The applicant	When the state asks for it in a disability review
DOH-5247	Medicaid Authorized Representative designation or change request	The applicant	To HRA or your county

Which forms you need, by situation

You do not have Medicaid yet and need help at home

Fill out DOH-4220 and, if you are 65+ or disabled, DOH-5178A. The supplement asks about resources.
Send them to HRA (NYC) or your county Department of Social Services, with copies of your proofs.
Once Medicaid is active, call the New York Independent Assessor at 1-855-222-8350 to schedule the assessment. See our NYIA scheduling guide.

You need care right away and have no one to help (Immediate Need)

Sign the attestation on page 3 of DOH-5786.
Get a DOH-5779 (adults 18+) or a physician's order (DOH-4359 or HCSP-M11Q) from the doctor or practitioner.
If you do not have Medicaid, add DOH-4220 and, if needed, DOH-5178A. If you have Medicaid without long-term care coverage, add DOH-5178A.
Send the packet to your local social services office, or HRA in NYC. Per DOH-5786, the office must ask for anything missing within 4 days, decide Medicaid within 7 days of getting what it needs, and decide on the home care within 12 days.

The person has Alzheimer's disease or dementia

Bring a completed DOH-5821 to the Community Health Assessment. The form itself warns that not having it at the assessment may affect eligibility for personal care, CDPAP, or joining an MLTC plan. It ties into the state's Minimum Needs rule, which counts supervision needs differently for people with these diagnoses. See our Minimum Needs guide.

Someone else will handle Medicaid paperwork

Use DOH-5247 to name an authorized representative with Medicaid.

Where to get the forms

Download from health.ny.gov/forms (links in the sources below).
Pick them up at an HRA Medicaid office in NYC, or your county Department of Social Services.
Ask the doctor's office for DOH-4359, DOH-5779, and DOH-5821; many offices already have them.

Common mistakes

Leaving the signature off DOH-5786 page 3.
Sending Immediate Need papers to NYIA. The state says they go to the local office.
Skipping DOH-5178A when the applicant is 65 or older.
Forgetting DOH-5821 at the assessment for someone with a dementia diagnosis.
Using an old version of a form. Download fresh from health.ny.gov.

Free public numbers used in this post

These free public lines can also help. They do not sell anything.

Next step

Want help with this? Get free one-on-one guidance.

Paperwork is where most home care requests stall. If you want someone to help you figure out which forms apply and in what order, our short home care form lets you ask for free one-on-one guidance. It is optional; the state and your local office make the decisions.

Get a plain-language summary

You can also call NY Connects free at 1-800-342-9871 or HIICAP at 1-800-701-0501. Free, any age, on Medicaid or not. They do not sell services.

Sources

Official pages checked September 23, 2026. Your own notice and current official guidance control if anything here differs.

NYS DOH, DOH-5786 Immediate Need Informational Notice and Attestation (11/22): https://www.health.ny.gov/forms/doh-5786.pdf
NYS DOH, DOH-5779 Practitioner Statement of Need: https://health.ny.gov/forms/doh-5779.pdf
NYS DOH, GIS 22 MA/09 (DOH-5779 for adults 18+, MD/DO/NP/PA; local office first): https://www.health.ny.gov/health_care/medicaid/publications/docs/gis/22ma09.pdf
NYS DOH, DOH-4220 Access NY Health Care Application: https://www.health.ny.gov/forms/doh-4220.pdf
NYS DOH, DOH-5178A Supplement A: https://www.health.ny.gov/forms/doh-5178a.pdf
NYS DOH, DOH-5821 Alzheimer's Disease and Dementia Diagnosis Verification (07/25): https://www.health.ny.gov/forms/doh-5821.pdf
NYS DOH, DOH-5139 Disability Questionnaire: https://www.health.ny.gov/forms/doh-5139.pdf
NYS DOH, DOH-5247 Medicaid Authorized Representative Designation: https://www.health.ny.gov/forms/doh-5247.pdf
NYS DOH, CDPAP and Minimum Needs Requirements: https://www.health.ny.gov/health_care/medicaid/program/longterm/cdpap/
NYS DOH, Local Departments of Social Services: https://www.health.ny.gov/health_care/medicaid/ldss.htm

Questions people ask

What is form DOH-5786?

It is the state's Immediate Need for Personal Care/Consumer Directed Personal Assistance Services Informational Notice and Attestation Form. The applicant signs the attestation on page 3 to ask for faster processing.

What is form DOH-5779?

It is the Practitioner Statement of Need for personal care or consumer directed services. For adults 18 and older it can be used instead of a physician's order in an Immediate Need request. An MD, DO, NP, or PA can complete it.

What is DOH-4359?

It is the physician's order for personal care or consumer directed personal assistance services. The DOH-5786 form lists HCSP-M11Q as another accepted physician's order form.

Do I need DOH-5178A?

Yes, if anyone applying is 65 or older, certified blind or disabled, chronically ill, or applying for nursing home care. It is not needed if you apply only for the Medicare Savings Program.

What is DOH-5821 used for?

It verifies an Alzheimer's disease or dementia diagnosis for people seeking personal care, CDPAP, or MLTC enrollment. It should be given to the assessor at the Community Health Assessment.

Next step

Want a written summary of which path matches what you described?

A few short questions and a way to reach you. It is held by this site only, never sent to any plan or agency, and does not decide eligibility or hours.

Get a plain-language summary

You can also call NY Connects free at 1-800-342-9871 or HIICAP at 1-800-701-0501. Free, any age, on Medicaid or not. They do not sell services.