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TCC Network Development Provider Application

 

Please complete the form to join Tri-County Care’s Provider Network. Our network includes providers of I/DD services, primary care, long term care, mental health services, support groups, as well as other related services.

This document will inform us about the services that your organization offers. If it’s not listed, feel free to add all the services and supports you provide in the Other box.

    Provider Demographic Information


























    Service Area
    Please check all NYS counties that you are licensed to provide services in:

    Please check all services your organization provides
    Medical:



    Clinical and Mental Health:



    I/DD Services:



    Home Care Services:



    Other:



    Support Groups
    Please list any support or social groups that your organization offers:



    Form completed by:





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