Providers

About ACA/NY’s Providers

Collaboration is essential to delivering exceptional services to people with intellectual and developmental disabilities. ACA/NY works closely with our experienced partners to provide the best connections, programs and supports for you and your family. Working together, we are committed to ensure that we support each person to live their healthiest and most meaningful life.

Become a Provider – ACA/NY Network Provider Application

Please complete the application to join ACA/NY’s Provider Network. Our network includes providers of intellectual and developmental disabilities services, OPWDD services, primary care, mental health, behavioral and substance abuse services, home care, long term care and many other related services. Please include all the services your organization offers. Please use the “Other” category if the services and supports you offer are not listed.

* required fields
Provider Information:
- Legal Provider Name*
- DBA (if applicable)
Primary Street Address*
Street Address Address Line 2 City State ZIP Code
- Primary Phone*
- Primary Email*
- Languages Your Organization Speaks*
- Accepted Insurances*
- Hours of Operation*
- Emergency After-Hours Phone Number*
- ADA Compliant*
  - Yes
  - No
- Do you have Regional Offices?*
  - Yes
  - No
Website*
Region Office #1*
Street Address Address Line 2 City State ZIP Code
Region Office #2
Street Address Address Line 2 City State ZIP Code
Service Area:
Check all New York State counties that you provide services in. Include both licensed and unlicensed programs.*
- All NYS Counties
- Albany
- Bronx
- Columbia
- Dutchess
- Fulton
- Greene
- Kings
- Montgomery
- Nassau
- New York City (Metro)
- Orange
- Putnam
- Queens
- Rensselaer
- Richmond
- Rockland
- Saratoga
- Schenectady
- Schoharie
- Suffolk
- Sullivan
- Ulster
- Warren
- Washington
- Westchester
Check all services and supports your organization provides.
I/DD Services*
- ACCES-VR
- Adaptive Services/Assistive Technology
- Applied Behavior Analysis (ABA)
- Community Classes through Self-Direction
- Community Habilitation
- Crisis Services for Individuals with Intellectual and Developmental Disabilities (CSIDD also known as NYSTART)
- Day Habilitation
- Day Habilitation-Supplemental
- Day Habilitation Without Walls
- Durable, Medical Equipment/Medical Supplies
- Environmental Modification
- Family Education and Training
- Family Support Services (FSS)
- Fiscal Intermediary (FI)
- Individualized Services & Goods (ISS)
- Intensive Behavioral Support (IBS)
- Pathways to Employment
- Residential Habilitation – Family Care
- Residential Habilitation – IRA
- Respite
- Support Brokers
- Supported Employment (SEMP)
- Transportation – Non-Emergency, Medical
- Transportation – Non-Emergency, Social
- Vehicle Modification
- Other
Medical*
- Allergist
- Ambulatory Care
- Audiology
- Cardiology
- Dentistry
- Dermatology
- Endocrinology
- ENT
- Gastroenterology
- Geneticist
- Gynecology
- Laboratory
- Neurology
- Nutrition
- Optometry
- Orthodontistry
- Pharmacy services
- Physiatry
- Podiatry
- Primary Care Physician
- Prosthetics and Orthotics
- Pulmonology
- Skilled Nursing Facility
- Urgent Care
- Urology
- Wellness Care
- Other
Clinical and Mental Health*
- Article 16 Clinic – OPWDD
- Article 28 – DOH
- Article 31 -OMH
- Article 32 – OASAS
- Behavioral Health
- Behavioral Health – ACT
- Behavioral Health – PROS
- Psychotherapy/Counseling
- Partial Hospitalization
- Psychiatry
- Psychology (psychological testing)
- Psychology (psychosocial evaluations)
- Social Work
- Substance Abuse
- Other
Home Care*
- Consumer Directed (Self-Directed) Personal Assistance Services (CDPAS)
- Education
- Health Home Aide (HHA)
- Hospice
- Live-In Caregiver
- Long-Term Services and Supports (LTSS)-Medical and Personal Care
- Medication Management
- Occupational Therapy
- Nursing
- Personal Care Aide (PCA)
- Physical Therapy
- Speech Therapy
- Other
Other Services*
- Access to Home
- Benefit Assistance
- Early Intervention
- End of Life Planning
- Foster Care
- Guardianship
- HCBS Care Management
- Immigration
- Legal
- Non-Medicaid Care Management
- Recreation/Support Groups
- School Advocacy
- Traumatic Brain Injury (TBI)
- Other
Recreation Activities/Support and Social Groups
Form Completed By:
- Full Name*
- Title*
- Contact Phone*
- Contact Email*
Date*
MM slash DD slash YYYY

We support each person to live their
healthiest and most meaningful life.

Advance Care Alliance of New York
1410 Broadway, 2nd Floor
New York, NY 10018

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Providers

About ACA/NY’s Providers

Become a Provider – ACA/NY Network Provider Application

Provider Information:

Service Area:

Check all services and supports your organization provides.

Form Completed By: