STC Questionnaire

Southern Tier Connect is a specialized Care Coordination Organization (CCO) that services individuals with intellectual and developmental disabilities. The following is meant to be a tool used to help in understanding if Southern Tier Connect may be the right service for you. The results of this tool are not intended to replace a formal eligibility authorization by the Office of People with Developmental Disabilities (OPWDD) nor is it intended to provide medical or other diagnostic advice or care. A formal eligibility determination by OPWDD will always be necessary.

Are you filling this questionnaire out for yourself or on behalf of someone?

Name of person submitting questionnaire on behalf of an individual

Submitter's First NameSubmitter's Last Name

Email of person submitting questionnaire on behalf of an individual

Submitter's email address

Phone Number of person submitting questionnaire on behalf of an individual

Submitter's phone numberFormat: (000) 000-0000.

Following the questionnaire, would you like someone to contact you regarding eligibility?

If yes, which method would you prefer we contact you?

Following the questionnaire, would you like someone to contact the individual? If so, please inform the individual that they will be contacted.

Southern Tier Connect

Name

Individual's First NameIndividual's Last Name

Email

Individual's email address

Phone Number

Individual's phone numberFormat: (000) 000-0000.

Eligibility Questionnaire