Application for CDPAS FLSA Pool Participation


This Application Form should be used by Consumer Directed Personal Assistance (CDPA) Fiscal Intermediaries (FI) seeking consideration to participate in the CDPAS Fair Labor Standards Act (FLSA) Pool Program. Participation is open to all Fi´s statewide.

FLSA Reference Material

The following reference materials may be of assistance when completing this application:

Submission Requirements

Submit one copy of the application to:

Subject line: CDPAS FLSA Application

The application must contain either an electronic signature or the original signature authorizing the application by the FI´s Director or other responsible signatory.

Acknowledgement/Completeness Review

The Office of Health Insurance Programs will electronically acknowledge receipt of the application. If the application is determined to be incomplete it will be returned for revision and resubmission. All applications to be considered must be fully completed and submitted by November 2, 2015. Applications that do not meet this criteria will not be considered for CDPAS FLSA BIP payments.

As part of the review process, applicants should be aware that additional information may be requested.

Whom to Contact for Assistance

Any questions concerning the application process should be directed to the Office of Health Insurance Programs, New York State Department of Health by e-mail at