Managed Long-Term Care ReferralTo make a referral please fill out the form below or give us a call at 1-888-477-4663.Managed Long-Term Care ReferralConsumer InformationReferral InformationReview0% Complete1 of 3 The referral can be completed by filling out the form below or by downloading the referral form (pdf), filling it out in its entirety and either:Email to: dl-enrollmentsubmissions@477home.orgFax to: (315) 477-9590Phone: (888) 477-4663Consumer Informaiton Name: * Date of Birth: * Address: City: State: NY AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip code: County of Residence: Albany County Allegany County Bronx County Broome County Cattaraugus County Cayuga County Chautauqua County Chemung County Chenango County Clinton County Columbia County Cortland County Delaware County Dutchess County Erie County Essex County Franklin County Fulton County Genesee County Greene County Hamilton County Herkimer County Jefferson County Kings County (Brooklyn) Lewis County Livingston County Madison County Monroe County Montgomery County Nassau County New York County (Manhattan) Niagara County Oneida County Onondaga County Ontario County Orange County Orleans County Oswego County Otsego County Putnam County Queens County Rensselaer County Richmond County (Staten Island) Rockland County Saint Lawrence County Saratoga County Schenectady County Schoharie County Schuyler County Seneca County Steuben County Suffolk County Sullivan County Tioga County Tompkins County Ulster County Warren County Washington County Wayne County Westchester County Wyoming County Yates County Phone Number: * (include area code) MCD ID / CIN #: CFEEC / Maximus Evaluation: (date completed / scheduled) If interpretation services are needed, specify language: If you are human, leave this field blank. Next