The M11q (form HCSP-M11Q, “Medical Request for Home Care”) is a three-page form that New York City’s Human Resources Administration (HRA) uses to collect a doctor’s description of a patient’s medical condition when the patient asks for Medicaid home care. The practitioner who examines the patient fills it in and signs it, and must not recommend a number of care hours. Since May 2022, adults applying for the first time usually go through the state’s independent assessor instead, so the M11q now matters mostly for reassessments and for children.
What is the M11q form and what is on it?
The M11q is a medical statement, not an application and not a decision. It does not say how many hours of care a person will get. The copy on nyc.gov carries the date 12/09/2014 and runs three pages. It begins with a patient medical release that lets the doctor share information with HRA, and it ends with a physician’s certification.
| Section of the form | What it asks |
|---|---|
| I. Client information | Name, birthdate, Social Security number, Medicaid number, home address, phone, contact person |
| A. Current condition | How long the doctor has treated the patient, exam date and place, primary and secondary diagnoses with ICD codes, and whether the condition is expected to recover, stay chronic or decline |
| B and C. Hospital and medication | Current hospital stay if any, each medication, and whether the patient can self-administer, needs reminding, supervision, help with preparation or administration |
| D. Medical treatment | A checklist of 20 items, such as wound dressings, bed-bound care, catheter care, oxygen, vital sign monitoring and therapy; also whether the patient can direct a home care worker |
| E and F. Equipment and referrals | Walker, wheelchair, hospital bed, commode and similar items the patient has or needs; referrals to a certified home health agency, hospice or nursing facility |
| G. Additional comments | Medical, social, family or home factors that affect the patient’s ability to function |
The physician’s certification says the patient can be cared for at home and that the description is accurate. It also repeats that the doctor is not to recommend hours of personal care.
Do I still need the M11q in 2026?
For many adults, no. New York’s Department of Health began using the New York Independent Assessor (NYIA) on May 16, 2022. For adults seeking personal care services or CDPAP for the first time, an independent clinician from the NYIA panel examines the person and issues a practitioner order, and the state says that order replaces the M11q and DOH-4359.
The same Department of Health notice says the older forms still apply to reassessments and to children, who need an exam by their own practitioner and a DOH-4359 or an M11q. Adults with an immediate need use a different form, DOH-5779.
| Situation | Paperwork the state describes |
|---|---|
| Adult, first-time request for personal care or CDPAP, or MLTC eligibility (since 16 May 2022) | NYIA nurse assessment plus NYIA practitioner order; M11q not required |
| Adult with an immediate need (since 1 July 2022) | DOH-5779 Practitioner Statement of Need |
| Adult reassessment | Plan or local district handles it; exam and DOH-4359 or M11q by the person’s own practitioner |
| Child, ages 0 to 17 | Exam by the child’s practitioner plus DOH-4359 or M11q |
One caution. The newest Department of Health notice I could read on the independent assessor program page is dated November 17, 2023, when moving reassessments to NYIA was postponed with no new date. Ask your plan or your local social services district which form is wanted today. NYIA’s helpline is (855) 222-8350. Our NYIA guide and our page on how Medicaid covers home care explain the rest of the process.
How is the M11q filled out and signed?
HRA’s one-page hint sheet for the form (HCSP-712B, dated 2010) lists eight rules. Ask the doctor’s office to read them before the visit.
- Fill in the client section. The patient’s name, address and Social Security number must be provided.
- Have the practitioner examine the patient and write the exam date. The date of the examination must be provided.
- Describe the condition accurately. The medical professional completes the form by describing the patient’s medical condition.
- Leave the hours blank. The doctor must not recommend or request a number of personal care hours.
- Get a New York licensed physician’s signature. The form lists the physician’s registry number and NPI number as mandatory fields.
- Sign and date within 30 days of the exam. The form itself says the signature date must be within thirty days after the medical exam.
- Send it in time. The signed copy must be forwarded within 30 calendar days after the examination.
The 2014 form says “physician” in its certification, while the Department of Health notes that since November 2021 physicians, nurse practitioners, physician assistants and specialist assistants can sign the order forms. If your practitioner is not a doctor, ask the plan or HRA whether they will accept the signature.
Why do M11q forms get sent back?
The reasons come straight from the eight rules and the mandatory fields on the form. A missing exam date, a missing registry or NPI number, or a late signature can all stall a request.
Families can prevent most of these with a short checklist at the doctor’s visit.
| Problem | How to prevent it |
|---|---|
| No exam date | Check the “Date of this Examination” line before leaving the office |
| Signed more than 30 days after the exam | Book the exam close to when the paperwork is needed, and ask for it to be signed that day |
| Registry or NPI number blank | These are starred “Mandatory” on the form; ask the office to check them |
| Hours written in | The doctor describes needs and limits only; hours are decided later |
| Vague condition description | Bring a short written list of what the person can and cannot do, such as bathing, dressing, transfers and medication |
Keep a copy of the signed form and note the date it was sent.
Where can I download the M11q form?
Use the HRA copy at nyc.gov, or our hosted PDF of the form. I found no 2026 revision of the form. Sites that advertise a “2026 version” are repeating the same document, and the nyc.gov file is dated 12/09/2014.
Is the M11q the same as the NYS Home Care Registry?
No. They share a search habit, not a purpose. The M11q is a medical form about a patient. The New York State Home Care Registry is a Department of Health database of home health aides and personal care aides who completed a state-approved training program.
On the registry search page you can look someone up by name, with at least two characters of the last name, or by the registry number the Department of Health assigned. The page warns that the state does not guarantee third-party information, that a certification may have lapsed, and that the listing may be outdated. Treat it as one check, not proof of good standing. Our guide to checking the Home Care Registry goes through a search step by step, and our companion page on how home care hours are decided covers what happens after the paperwork.
Does VNS Health home care use the M11q?
VNS Health’s own page does not mention the M11q. It says home care “requires a medical referral” and that its referral forms need a physician’s signature. That is VNS Health’s referral process, separate from the HRA form above.
The same page says personal care, usually from a home health aide, can be paid out of pocket, and gives 1-888-735-8913 for personal care. If you are comparing agencies for Medicaid or private pay, see how to choose a home care agency in New York.
We are a licensed home care agency in Brooklyn and Queens (New York State Department of Health licence #2572L001). If you are not sure which form your situation needs, call (718) 232-2777 or use our contact page, and we will point you to the right office to ask.
Program rules and forms change. Everything above was checked on 9 October 2026 against nyc.gov, health.ny.gov and vnshealth.org. The Department of Health program pages block automated readers, so the independent assessor pages were read through the Department’s mirror site. Confirm which form you need with your Medicaid plan, the independent assessor or your HRA caseworker.
Frequently asked questions
What is the M11q form?
It is the HCSP-M11Q “Medical Request for Home Care,” a New York City HRA form on which a practitioner describes a patient’s diagnoses, medications, treatments and equipment needs. It supports a request for home care and does not set the number of hours.
Who has to sign the M11q?
The form is written for a New York licensed physician, and the physician’s registry and NPI numbers are mandatory. Since November 2021 the Department of Health has allowed nurse practitioners and physician assistants to sign the related order forms.
How long is the M11q valid?
The signature must be dated within 30 days after the exam, and the signed form must be sent within 30 calendar days after the exam, according to HRA’s hint sheet. A form that is older than that may have to be redone.
Can the doctor write how many hours of care I need?
No. The form says the doctor must not recommend the number of hours of personal care. Hours are decided in the assessment and authorization that follow.
Do first-time adult applicants still need an M11q?
Usually not. For adults asking for personal care or CDPAP for the first time since May 16, 2022, the independent assessor’s practitioner order replaces it, according to the Department of Health. Reassessments and children still use DOH-4359 or the M11q.
Is there a 2026 version of the M11q?
I could not find one. The copy on nyc.gov is dated 12/09/2014. Check nyc.gov for the current blank form before using a copy from another site.
Is the NYS Home Care Registry the same thing as the M11q?
No. The registry is a state database of home health aides and personal care aides who completed approved training. The M11q is a medical form about the patient.
