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DOH-4220-I3/15Page2
CONFIDENTIALITY STATEMENTAlloftheinformationyouprovideonthisapplicationwillremainconfidential.TheonlypeoplewhowillseethisinformationaretheFacilitatedEnrollersandtheStateorlocalagenciesandhealthplanswhoneedtoknowthisinformationinordertodetermine if you (the applicant) and your household members are eligible. The person helping you with this application cannot discuss theinformationwithanyone,exceptasupervisorortheStateorlocalagenciesorhealthplanswhichneedthisinformation.
Weneedtobeabletocontactthepeopleapplyingforhealthinsurance.Thehomeaddressiswherethepeopleapplyingforhealthinsurancelive.Themailingaddress,ifdifferent,iswhereyouwantustosendhealthinsurancecardsandnoticesaboutyourcase.Youcanalsotellusifyouwantsomeoneelsetogetinformationaboutyourcaseand/ortobeabletodiscussyourcase.
INSTRUCTIONS
PLEASE READ the entire application booklet before you begin to fill out the application. If you are applying ONLY for children or if you are a pregnant woman applying alone, you must complete only Sections A through G and Sections I and J. Other applicants must complete all sections.
If you are 65 years old or older, certified blind, certified disabled, or institutionalized and applying for coverage of nursing home care, you must also complete Supplement A. The supplement includes questions about your resources, such as money in the bank or property you own.
Whenever you see the words on the application refer to the “Documentation Needed When You Apply for Health Insurance” section for a listing of acceptable supporting documents.
HOW TO GET HELP When applying for public health insurance, you DO NOT need to visit your local department of social services or a Facilitated Enroller for an interview, but you MAY come in or contact a Facilitated Enroller for help filling out this application. You can get a list of Facilitated Enrollers where you got this application, or by calling 1-800-698-4543. ALL HELP IS FREE. (1-877-898-5849 TTY line for the hearing impaired)
PURPOSE OF THIS APPLICATION Complete this application if you want health insurance to cover medical expenses. This application can be used to apply for Medicaid, the Family Planning Benefit Program, or for assistance paying your health insurance premiums. You can apply for yourself and/or immediate family members living with you.
IF YOU NEED HELP COMPLETING THIS APPLICATION DUE TO A DISABILITY, CALL YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. THEY WILL MAKE EVERY EFFORT TO PROVIDE REASONABLE ACCOMMODATIONS TO ADDRESS YOUR NEEDS.
Pleaseincludeinformationforeveryonewholiveswithyoueveniftheyarenotapplyingforhealthinsurance.Itisimportantthatyoulisteveryonewholiveswithyousothatwecanmakeacorrecteligibilitydecision.Includemaidenname(legalnamebeforemarriage),ifthisappliestotheperson.AlsoincludeCity,StateandCountryofbirth.IfapersonwasbornoutsideoftheUnitedStates,justwritethecountryofbirth.Wealsoneed,foreachpersonapplying,his/hermother’sfullmaidenname(firstandlastname).Thisinformationmaybeusedtoobtainproofoftheapplicant’sbirthdateundercertaincircumstances.
Is this person pregnant?Ifso,whenisherbabyduetobeborn?Thisinformationhelpsusdeterminethesizeofyourfamily.Apregnantwomancountsastwopeople.
Relationship to the person on Line 1.ExplainhoweachpersonisrelatedtothepersonlistedonLine1(forexample,spouse,child,step-child,brother,sister,niece,nephew,etc.)
Public Health Coverage.IfyouoranyonewholiveswithyouisalreadyenrolledorwaspreviouslyenrolledinMedicaid,theFamilyPlanningBenefitProgram,oranyotherformofpublicassistancesuchasFoodStamps,weneedtoknow.Also,tellustheidentificationnumberontheNewYorkStateBenefitIdentificationCard.
Social Security Number.ASocialSecurityNumbershouldbeprovidedforallpersonsapplying,ifthepersonhasone.IfthepersondoesnothaveaSocialSecurityNumber,leavethisboxblank.
Citizenship and Immigration Status.Thisinformationisneededonlyforthosepeopleapplyingforhealthinsurance.Pregnantwomendonothavetocompletethisquestion.Tobeeligibleforhealthinsurance,otherpersonsage19andovermustbeU.S.citizensorbeinaneligibleimmigrationcategory.WeneedtoseeeitheroriginaldocumentationofU.S.citizenshipandidentity,orcopiesofthesedocuments.Pleasecontactyourlocaldepartmentofsocialservicesorcall1-800-698-4543tofindoutwhereyoucanbringthesedocuments.PleasenotethatifyouareonMedicare,orreceivingSocialSecurityDisabilitybutarenotyeteligibleforMedicare,itisnotnecessarytodocumentcitizenshiporidentity.
SEND PROOF
SECTION A Applicant’s Information
SECTION B Household Information
Inthissection,listalltypesofincome(moneyreceived)andtheamountsreceivedbythepeopleyoulistedinSectionB.
Pleasetellushowmuchyoumakebeforetaxesaretakenout.
Ifthereisnomoneycomingintoyourhome,explainhowyouarepayingforyourlivingexpenses,suchasfoodandhousing.
Weneedtoknowifyouhavechangedjobsorifyouareastudent.
Wealsoneedtoknowifyoupayanotherpersonorplace,suchasadaycarecenter,totakecareofyourchildrenordisabledspouseorparentwhileyouareworkingorgoingtoschool.Ifyoudo,weneedtoknowhowmuchyoupay.Wemaybeabletodeductsomeoftheamountthatyoupayforthesecostsfromtheamountwecountasyourincome.
PUBLIC CHARGE INFORMATION
TheUnitedStatesCitizenshipandImmigrationServices(USCIS)hasstatedthatenrollmentinMedicaid,ortheFamilyPlanningBenefitProgramCANNOTaffectaperson’sabilitytogetagreencard,becomeacitizen,sponsorafamilymember,ortravelinandoutofthecountry.ThisisnottrueifMedicaidpaysforlong-termcareinaplacesuchasanursinghomeorpsychiatrichospital.
Writeinyourmonthlycostofhousing.Thisincludesyourrent,monthlymortgagepaymentorotherhousingpayment.Ifyouhaveamortgagepayment,includepropertytaxesintheamountyoutellus.Ifyoushareyourhousingexpensesoryourrentissubsidized,pleaseonlytellushowmuchYOUpaytowardyourrentormortgage.Ifyoupayforyourwater,tellushowmuchyoupayandhowoften.
Ifyouhavepaidorunpaidmedicalbillsfromthepastthreemonths,Medicaidmaybeabletopayforthesecosts.Letusknowwhothesebillsareforandinwhichmonths.Includecopiesofthemedicalbillswiththisapplication.Note:Thisthree-monthperiodbeginswhenthelocaldepartmentofsocialservicesreceivesyourapplicationorwhenyoumeetwithaFacilitatedEnroller.Youwillneedtotelluswhatyourincomewasforanypastmonthsinwhichyouhavemedicalbillssothatwecanseeifyouareeligibleduringthattime.Wealsoaskaboutwhereyoulivedinthepastthreemonths,becausethismayaffectourabilitytopayforpastbills.Weaskaboutanypendinglawsuitsorhealthissuescausedbysomeoneelsesoweknowifsomeoneelseshouldpayforanyportionofyourmedicalcarecosts.
Thesequestionshelpusdeterminewhichprogramisbestforeachapplicant,andwhatservicesmaybeneeded.Apersonwithadisability,seriousillnessorhighmedicalbillsmaybeabletogetmorehealthservices.Youmayhaveadisabilityifyourdailyactivitiesarelimitedbecauseofanillnessorconditionthathaslastedorisexpectedtolastforatleast12months.Ifyouareblind,disabled,chronicallyillorneednursinghomecare,youwillneedtocompleteSupplementA.Ifneitheryounoranyoneapplyingisblind,disabled,chronicallyillorinanursinghome,gotoSectionG.
Itisimportanttotelluswhetheranyoneapplyingiscoveredorcouldbecoveredbysomeoneelse’shealthinsurance.Thisinformationmayaffecttheireligibilityforcoverage;forsomeapplicants,wecandeducttheamountthatyoupayforhealthinsurancefromtheamountwecountasyourincome;orwemaybeabletopaythecostofyourhealthinsurancepremiumifwedetermineitiscosteffective.Wemaybeabletohelppayforhealthinsurancepremiumsifyouhaveorcangetinsurancethroughyourjob.Wewillneedtogathermoreinformationabouttheinsuranceandwillmailaninsurancequestionnairetoyou.
The State will not report any information on this application to the USCIS.
Race/Ethnic Group. Thisinformationisoptionalanditwillhelpusmakesurethatallpeoplehaveaccesstotheprograms.Ifyoufilloutthisinformation,usethecodeshownontheapplicationthatbestdescribeseachperson’sraceorethnicbackground.Youmaypickmorethanone.
DOH-4220-I3/15Page3
SECTION F Blind, Disabled, Chronically Ill or Nursing Home Care
SECTION C Household Income (Money Received)
SECTION G Additional Health Questions
SECTION D Health Insurance
SECTION E Housing Expenses
What is a Health Plan?ApplyingforprogramsthroughAccessNYHealthCaremaymeanyougetyourhealthcarecoveragethroughaManagedCareplan.Whenyoujoinaplan,youchooseonedoctor(PrimaryCareProviderorPCP)fromthatplantotakecareofyourregularneeds.Ifyouwanttokeepthedoctoryouhave,youneedtopicktheplanthatworkswithyourdoctor.ManagedCarehealthplansfocusonpreventivecaresosmallproblemsdonotbecomebigones.Ifyouneedaspecialist,yourPCPwillreferyoutoone.
PleasereadtheparagraphinthissectioncarefullyandreadtheTerms, Rights and Responsibilitiessection.Youmustthensignanddatetheapplication.
If any applicants have an absent spouse or parent, you must complete this section so we can see if medical support is available to you or your child.
Pregnant women do not have to answer these questions until 60 days after the birth of their child.Allotherpeoplewhoareapplyingandareage21orovermustbewillingtoprovideinformationaboutaparentofanapplyingminororaspouselivingoutsidethehometobeeligibleforhealthinsurance,unlessthereisgoodcause.Anexampleof“goodcause”isfearofphysicaloremotionalharmtoyouorafamilymember.Question2referstothePARENT ofanyapplyingchildunderage21.Question3referstotheSPOUSEofanyoneapplying.
Iftheparentsarenotwillingtoprovidethisinformation,theapplyingchildmaystillbeeligibleforMedicaid.
Who Must Choose a Health Plan?MOSTpeoplewhoareeligibleforMedicaidMUST chooseahealthplantogetmostoftheirMedicaidbenefits.Keepreadingtofindouthowtogetmoreinformationonthis.
How Do I Know What Health Plan to Choose and If I Can Enroll?ForMedicaid,ifyouwanttofindoutmoreabouthowmanagedcareplanswork,ifyouhavetojoin,andhowtochooseaplan,callMedicaid CHOICEat1-800-505-5678,orcallorvisityourlocaldepartmentofsocialservices.AskforaManagedCareEducationPacket.InformationabouthealthplansisalsoontheNYSDOHwebsiteatwww.nyhealth.gov.Youcanalsoenrollbyphone,bycalling1-800-505-5678.
NOTE: IfyouorafamilymemberarefoundeligibleforMedicaid,andareinacountythatdoesnotrequirepeopleonMedicaidtojoinahealthplan,youwillstillbeenrolledinthehealthplanyouchooseifitprovidesMedicaid,unlessyouchecktheboxontheapplicationthatsaysyoudon’twanttobeenrolled,ortellusyoudonotwanttobeenrolledbycallingorwritingtoyourlocaldepartmentofsocialservices.
DOH-4220-I3/15Page4
SECTION H Parent or Spouse Not Living in the Household or Deceased
SECTION I Health Plan Selection
SECTION J Signature
DO
CUM
ENTS
NEE
DED
WH
EN Y
OU
APP
LY F
OR
HEA
LTH
INSU
RAN
CE
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can
prov
ide
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ofth
efo
llow
ing
docu
men
tsto
pro
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oth
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zens
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tifica
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tity.
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ave
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f yo
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gett
ing
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t us
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YOU
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OT N
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TO S
HOW
US
ALL
OF T
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e on
ly n
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men
ts th
at a
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to y
ou o
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re a
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see
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all 1
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tity
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d U.
S. ci
tizen
ship
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umen
ts. M
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loca
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artm
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ocum
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lso
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DOH-4220-I3/15Page5
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DED
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APP
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LTH
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RAN
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COM
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UTUR
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NEM
PLOY
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LAW
SUIT
: You
mus
t pro
vide
a le
tter
, wri
tten
stat
emen
t, or
copy
of c
heck
or
stub
s, fr
om th
e em
ploy
er, p
erso
n or
age
ncy
prov
idin
g th
e in
com
e. Y
OU D
O N
OT N
EED
TO S
HOW
US
ALL
OF T
HESE
DOC
UMEN
TS, o
nly
the
ones
that
app
ly to
you
and
the
peop
le li
ving
with
you
. On
e pr
oof f
or e
ach
type
of i
ncom
e yo
u ha
ve is
requ
ired
. Pro
vide
the
mos
t rec
ent p
roof
of i
ncom
e be
fore
taxe
s and
any
oth
er d
educ
tions
. The
pro
of m
ust b
e da
ted,
incl
ude
the
empl
oyee
’s na
me
and
show
gro
ss in
com
e fo
r the
pay
per
iod.
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pro
of m
ust b
e fo
r the
last
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wee
ks, w
heth
er y
ou g
et p
aid
wee
kly,
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eekl
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r mon
thly
. It i
s im
port
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hat t
hese
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curr
ent.
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vide
nce
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ontin
uous
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iden
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ary
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972
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listb
elow
cont
ains
som
eof
the
mos
tcom
mon
Uni
ted
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esC
itize
nshi
pan
dIm
mig
ratio
nSe
rvic
es(U
SCIS
)for
msu
sed
tosh
owy
ouri
mm
igra
tion
stat
us.
This
list
isn
ota
ll-in
clus
ive.
Ify
oud
ono
thav
eon
eof
thes
edo
cum
ents
,ple
ase
refe
rto
the
“How
toG
etH
elp”
sect
ion
ofth
ein
stru
ctio
ns.
We
need
tose
eON
Eof
the
follo
win
gdo
cum
ents
top
rove
bot
hIm
mig
ratio
nSt
atus
,Ide
ntity
and
you
rDat
eof
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h:
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men
ts w
ith *
nex
t to
it al
so sh
ow d
ate
of b
irth
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** In
com
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turn
s fo
r oth
er th
an s
elf-e
mpl
oyed
may
be
used
for
appl
icat
ions
prior
to A
pril
1 of
the
follo
win
g ye
ar.
If yo
u ar
e no
t a U
.S. C
itize
n
☐
Lea
se/l
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twith
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dres
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his a
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hom
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dres
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t you
wri
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Sec
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A of
the
appl
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The
pro
of m
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ted
with
in 6
mon
ths o
f whe
n yo
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the
appl
icat
ion.
DOH-4220-I3/15Page6
DO
CUM
ENTS
NEE
DED
WH
EN Y
OU
APP
LY F
OR
HEA
LTH
INSU
RAN
CEIf
you
pay
to h
ave
care
for y
our c
hild
ren
or p
aren
ts w
hile
you
wor
k, p
rovi
de o
ne o
f the
follo
win
g:
☐
Writ
ten
stat
emen
tfro
md
ayca
rece
nter
oro
ther
child
/adu
ltca
rep
rovi
der
☐
Can
cele
dch
ecks
orr
ecei
ptst
hats
how
you
rpay
men
ts
Proo
f of h
ealth
insu
ranc
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rovi
de a
ll th
at a
pply
:
☐
Pro
ofo
fcur
rent
insu
ranc
e(In
sura
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polic
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rtifi
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ofI
nsur
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orI
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lthIn
sura
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Term
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icar
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rd(R
ed,W
hite
and
Blu
eCa
rd)
If yo
u ha
ve m
edic
al b
ills i
n th
e la
st th
ree
mon
ths,
pro
vide
all
the
follo
win
g:
Ford
eter
min
atio
nof
elig
ibili
tyfo
rmed
ical
exp
ense
sfro
mth
epa
stth
ree
mon
ths:
☐
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ofo
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fort
hem
onth
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hich
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expe
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rred
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Pro
ofo
fres
iden
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last
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ly if
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and
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☐
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kac
coun
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tem
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IRA
and
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☐
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bond
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ssta
tem
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☐
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epo
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lest
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tem
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☐
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gst
uden
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DOH-4220-I3/15Page7
Lega
l Fir
st, M
iddl
e, L
ast N
ame
Date
of
Birt
h
Is th
is
pers
on
appl
ying
fo
r hea
lth
insu
ranc
e?
Is th
is
pers
on
preg
nant
?
Is th
is
pers
on th
e
pare
nt o
f an
app
lyin
g ch
ild?
Wha
t is t
he
rela
tions
hip
to th
e pe
rson
in
Box
1?
If th
is p
erso
n ha
s or h
ad
publ
ic h
ealth
cove
rage
in
the
past
, che
ck
the
box
that
app
lies.
Soci
al
Secu
rity
N
umbe
r (if
you
ha
ve o
ne)
*Rac
e/
Ethn
ic
Grou
p
01
02Lega
l Fir
st N
ame
Anot
her P
hone
#
Stre
et
Stre
etAp
t.#
Apt.#
City
City
Nam
e
Stre
et
City
Stat
e
Stat
e
Stat
eZi
p Co
de
Zip
Code
Zip
Code
Coun
ty
Apt.#
Wha
t Lan
guag
e Do
You
:
Mid
dle
Initi
alLe
gal L
ast N
ame
Prim
ary
Phon
e #
Hom
e
C
ell
Wor
k
Othe
rH
ome
Cel
lW
ork
Ot
her
Spea
k?Re
ad?
HOM
E AD
DRES
S
ofth
epe
rson
sap
plyi
ngfo
rhea
lthin
sura
nce
Ch
eck
here
ifh
omel
ess
MAI
LIN
G AD
DRES
S
ofth
epe
rson
sap
plyi
ngfo
rhea
lthin
sura
nce
ifdi
ffere
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oma
bove
.
OPTI
ONAL
:Ift
here
isa
noth
erp
erso
nyo
uw
ould
like
tore
ceiv
eyo
ur
Med
icai
dno
tices
,ple
ase
prov
ide
this
per
son’
sco
ntac
tinf
orm
atio
n.
Iwan
tthi
sco
ntac
tper
son
to:
Appl
yfo
rand
/orr
enew
Med
icai
dfo
rme
Disc
uss
my
Med
icai
dap
plic
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nor
case
,ifn
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Ge
tnot
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corr
espo
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Phon
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Chec
k al
l th
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pply
Hom
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ork
Othe
r
Yes
No
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No
Mal
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Mal
eF
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Yes
No
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No
Yes
No
Wha
tis
the
Du
eDa
te?
Yes
No
Wha
tis
the
Du
eDa
te?
SELF
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
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own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
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igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
U.S
.Citi
zen
Im
mig
rant
/non
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zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
/
/
/
/
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
SEND
PRO
OF
Plea
se m
ark
one
box
that
in
dica
tes y
our c
urre
nt
Citiz
ensh
ip o
r Im
mig
ratio
n St
atus
. N
ot n
eede
d fo
r pr
egna
nt w
omen
SEND
PRO
OF
SEND
PRO
OF
*Rac
e/Et
hnic
Gro
up C
odes
(opt
iona
l):A
-Asi
an,B
-Bla
cko
rAfr
ican
-Am
eric
an,I
-Nat
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ican
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lask
anN
ativ
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-Nat
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Haw
aiia
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oth
erP
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sote
llus
ify
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reH
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nico
rLat
ino-
H
Refe
r to
the
“Doc
umen
ts N
eede
d W
hen
You
Appl
y fo
r Hea
lth In
sura
nce”
in th
e in
stru
ctio
ns o
n pa
ges 1
-3, “
Docu
men
tatio
n Ch
eckl
ist f
or H
ealth
Insu
ranc
e”, f
or a
list
of d
ocum
ents
that
pro
ve Id
entit
y, C
itize
nshi
p or
Imm
igra
tion
Stat
us.
SEND
PRO
OF
/
/
/
/
DOH-4220-I3/15Page8
SEC
TIO
N A
A
pplic
ant’s
Info
rmat
ion
Ple
ase
tell
us w
ho y
ou a
re a
nd h
ow to
cont
act y
ou.
Ifyo
uliv
ein
the
hous
ehol
d,s
tart
with
you
rsel
f.If
you
don
ot,s
tart
with
any
adu
ltsw
holi
vein
the
hous
ehol
d.L
istt
hefu
llle
galn
ames
oft
hep
erso
nsa
pply
ing
foro
ralre
ady
rece
ivin
gM
edic
aid
and
list t
he ID
Num
ber f
rom
thei
r Ben
efit C
ard
or h
ealth
pla
n ID
car
d.Y
oum
ustp
rovi
dein
form
atio
nfo
rhou
seho
ldm
embe
rsin
clud
ing:
par
ents
,ste
p-pa
rent
s,an
dsp
ouse
s.Yo
um
ayp
rovi
dein
form
atio
nfo
roth
erh
ouse
hold
mem
bers
(for
exa
mpl
e,a
dep
ende
ntch
ildu
nder
the
age
of2
1).L
istin
g ot
her h
ouse
hold
mem
bers
may
allo
w u
s to
give
you
a h
ighe
r el
igib
ility
leve
l. Pr
egna
nt w
omen
and
child
ren
unde
r 19
may
be
elig
ible
for h
ealth
insu
ranc
e re
gard
less
of i
mm
igra
tion
stat
us.
SEC
TIO
N B
Hou
seho
ld In
form
atio
n
ACC
ESS
NY
HEA
LTH
CA
RE M
edic
aid
Prin
t cle
arly
in b
lue
or b
lack
ink.
An
inco
mpl
ete
appl
icat
ion
cann
ot b
e pr
oces
sed
and
will
resu
lt in
a d
elay
of a
dec
isio
n on
you
r app
licat
ion.
Lega
l Fir
st, M
iddl
e, L
ast N
ame
Date
of
Birt
h
Is th
is
pers
on
appl
ying
fo
r hea
lth
insu
ranc
e?
Is th
is
pers
on
preg
nant
?
Is th
is
pers
on th
e
pare
nt o
f an
app
lyin
g ch
ild?
Wha
t is t
he
rela
tions
hip
to th
e pe
rson
in
Box
1?
If th
is p
erso
n ha
s or h
ad
publ
ic h
ealth
cove
rage
in
the
past
, che
ck
the
box
that
app
lies.
Soci
al
Secu
rity
N
umbe
r (if
you
ha
ve o
ne)
*Rac
e/
Ethn
ic
Grou
p
03
04 05 06 07
Yes
No
Mal
eF
emal
e
Yes
No
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
eTh
isP
erso
n’s
Mot
her’s
Ful
lMai
den
Nam
e
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
Yes
No
Wha
tis
the
Du
eDa
te?
/
/
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
Yes
No
Mal
eF
emal
e
Yes
No
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
/
/
/
/
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
Yes
No
Mal
eF
emal
e
Yes
No
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
/
/
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
Yes
No
Mal
eF
emal
e
Yes
No
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
/
/
This
Per
son’
sM
othe
r’sF
ullM
aide
nN
ame
Yes
No
Mal
eF
emal
e
Yes
No
Med
icai
d
Fam
ilyH
ealth
Plu
s
IDN
umbe
rfro
m
Bene
fitC
ard/
Plan
Car
d,
ifkn
own:
U.S
.Citi
zen
Im
mig
rant
/non
-citi
zen
Ente
rthe
dat
eyo
ure
ceiv
ed
your
imm
igra
tion
stat
us
____
__/_
____
_/__
____
Mon
th
Da
y
Yea
r
Non
-imm
igra
nt(V
isa
hold
er)
Non
eof
the
abov
e
Full
Mai
den
Nam
e(p
erso
n’s
birt
hna
me
befo
reth
eyw
ere
mar
ried)
City
ofB
irth
Stat
eof
Birt
hCo
untr
yof
Birt
h
/
/
Isa
nyon
ein
you
rhou
seho
lda
vet
eran
?Y
es
N
o
Ify
es,n
ame:
SEND
PRO
OF
Plea
se m
ark
one
box
that
in
dica
tes y
our c
urre
nt
Citiz
ensh
ip o
r Im
mig
ratio
n St
atus
. N
ot n
eede
d fo
r pr
egna
nt w
omen
*Rac
e/Et
hnic
Gro
up C
odes
(opt
iona
l):A
-Asi
an,B
-Bla
cko
rAfr
ican
-Am
eric
an,I
-Nat
ive
Amer
ican
orA
lask
anN
ativ
e,P
-Nat
ive
Haw
aiia
nor
oth
erP
acifi
cIsl
ande
r,W
-Whi
te,U
-Unk
now
n.P
leas
eal
sote
llus
ify
oua
reH
ispa
nico
rLat
ino-
H
Refe
r to
the
“Doc
umen
ts N
eede
d W
hen
You
Appl
y fo
r Hea
lth In
sura
nce”
in th
e in
stru
ctio
ns o
n pa
ges 1
-3, “
Docu
men
tatio
n Ch
eckl
ist f
or H
ealth
Insu
ranc
e”, f
or a
list
of d
ocum
ents
that
pro
ve Id
entit
y, C
itize
nshi
p or
Imm
igra
tion
Stat
us.
SEND
PRO
OF
SEND
PRO
OF
Yes
No
Wha
tis
the
Du
eDa
te?
/
/
Yes
No
Wha
tis
the
Du
eDa
te?
/
/
Yes
No
Wha
tis
the
Du
eDa
te?
/
/
Yes
No
Wha
tis
the
Du
eDa
te?
/
/
DOH-4220-I3/15Page9
SEC
TIO
N B
H
ouse
hold
Info
rmat
ion
(Con
tinue
d fr
om p
revi
ous p
age)
Nam
e of
Per
son
Type
of I
ncom
e/So
urce
How
Muc
h? (b
efor
e ta
xes)
How
Oft
en? (
wee
kly,
mon
thly
)
Nam
e of
Per
son
Type
of I
ncom
e/So
urce
How
Muc
h? (b
efor
e ta
xes)
How
Oft
en? (
wee
kly,
mon
thly
)
Nam
e of
Per
son
Type
of I
ncom
e/So
urce
How
Muc
h? (b
efor
e ta
xes)
How
Oft
en? (
wee
kly,
mon
thly
)
Nam
e of
Per
son
Type
of I
ncom
e/Em
ploy
er N
ame
How
Muc
h? (b
efor
e ta
xes)
How
Oft
en? (
wee
kly,
mon
thly
)
Earn
ings
from
Wor
k:In
clud
esw
ages
,sal
arie
s,co
mm
issi
ons,
tips,
over
time,
sel
f-em
ploy
men
t.I
fyou
are
sel
f-em
ploy
edch
eck
here
:
Ch
eck
here
ifn
oea
rnin
gsfr
omw
ork:
Unea
rned
Inco
me:
Incl
udes
Soc
ialS
ecur
ityB
enefi
ts,d
isab
ility
pay
men
ts,u
nem
ploy
men
tpay
men
ts,i
nter
esta
ndd
ivid
ends
,vet
eran
s’be
nefit
s,W
orke
rs’C
ompe
nsat
ion,
ch
ilds
uppo
rtp
aym
ents
/alim
ony,
rent
alin
com
e,p
ensi
on,a
nnui
ties
and
trus
tinc
ome.
Che
ckh
ere
ifno
une
arne
din
com
e:
Cont
ribu
tions
: Mon
eyfr
omre
lativ
eso
rfrie
nds,
room
ers
orb
oard
ers
(incl
ude
mon
eyth
ata
nyon
egi
ves
you
each
mon
thto
hel
pm
eetl
ivin
gex
pens
es).
Che
ckh
ere
ifno
cont
ribut
ions
:
Othe
r: Te
mpo
rary
(cas
h)A
ssis
tanc
e,S
uppl
emen
talS
ecur
ityIn
com
e(S
SI)p
aym
ents
,stu
dent
gra
nts,
orlo
ans.
Che
ckh
ere
ifno
ne:
Child
’s/ad
ult’s
nam
e:H
owm
uch?
$H
owO
ften?
(wee
kly,
ever
ytw
ow
eeks
,mon
thly
)
Child
’s/ad
ult’s
nam
e:H
owm
uch?
$H
owO
ften?
(wee
kly,
ever
ytw
ow
eeks
,mon
thly
)
Child
’s/ad
ult’s
nam
e:H
owm
uch?
$H
owO
ften?
(wee
kly,
ever
ytw
ow
eeks
,mon
thly
)
2.I
fthe
reis
no
inco
me
liste
dab
ove,
ple
ase
expl
ain
how
you
are
livi
ng:
(For
exa
mpl
e: li
ving
with
frie
nd o
r re
lati
ve)
1.D
oyo
uor
any
app
lyin
gad
ulti
nSe
ctio
nB
have
no
inco
me?
N
o
Yes
W
ho?
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_
3.H
ave
you
ora
nyon
ew
hois
app
lyin
gch
ange
djo
bso
rsto
pped
wor
king
inth
ela
st3
mon
ths?
N
oY
es
Ifye
s:Y
ourl
astj
obw
as:D
ate
___
___/
____
__/_
____
_N
ame
ofE
mpl
oyer
:
4.A
rey
ouo
rany
one
who
isa
pply
ing
ast
uden
tin
avo
catio
nal,
unde
rgra
duat
e,o
rgra
duat
epr
ogra
m?
N
oY
es
Ifye
s:
Ful
lTim
e
Par
tTim
e
Und
ergr
adua
te
Gra
duat
e
Stud
ent’s
Nam
e:
5.D
oyo
uha
veto
pay
forc
hild
care
(orf
orca
reo
fad
isab
led
adul
t)in
ord
erto
wor
kor
go
tos
choo
l?
No
Y
es
6.If
you
are
not
elig
ible
forM
edic
aid
cove
rage
,you
may
stil
lbe
elig
ible
fort
heF
amily
Pla
nnin
gBe
nefit
Pro
gram
.Are
you
inte
rest
edin
rece
ivin
gco
vera
gefo
rFam
ilyP
lann
ing
Serv
ices
onl
y?
No
Y
es
DOH-4220-I3/15Page10
SEC
TIO
N C
H
ouse
hold
Inco
me
Wri
te th
e ty
pes o
f mon
ey a
nd th
e am
ount
rece
ived
by
ever
yone
list
ed in
Sec
tion
B an
d SE
ND P
ROOF
1.D
oes
anyo
new
hois
app
lyin
gha
veM
edic
are?
N
o
Y
es
I
f yes
, inc
lude
a co
py o
f you
r car
d (r
ed, w
hite
and
blu
e ca
rd),
for e
ach
Med
icar
e be
nefic
iary
. Co
mpl
ete
the
rest
of t
his a
pplic
atio
n an
d co
mpl
ete
Supp
lem
ent A
.
2.D
oesa
nyon
ew
hois
app
lyin
gal
read
yha
veo
ther
com
mer
cial
hea
lthin
sura
nce,
incl
udin
glo
ngte
rmca
rein
sura
nce?
No
Y
es
If ye
s, y
ou m
ust s
end
a co
py o
f the
fron
t and
bac
k of
th
e in
sura
nce
card
with
this
app
licat
ion.
N
ame
ofIn
sure
d(p
rimar
y)_
____
____
____
____
____
____
____
____
___
Per
sons
Cov
ered
___
____
____
____
____
____
____
____
__
Cost
ofP
olic
y_
____
____
___
End
date
ofc
over
age,
ife
ndin
gso
on_
____
_/__
____
_/__
____
_
Not
e:If
you
are
app
lyin
gfo
rthe
Med
icar
eSa
ving
sPr
ogra
mo
nly
(MSP
),go
toS
ectio
nG.
You
do
NOT
nee
dto
com
plet
eSu
pple
men
tA.
3.D
oes
your
curr
entj
obo
fferh
ealth
insu
ranc
e?W
e m
ay b
e ab
le to
hel
p pa
y fo
r it.
No
Y
es
Ifye
s,a
“Req
uest
forI
nfor
mat
ion
Empl
oyer
Spo
nsor
edH
ealth
Insu
ranc
e”fo
rmw
illb
ese
ntto
you
.
You
and
your
fam
ily m
ay st
ill b
e el
igib
le e
ven
if yo
u ha
ve o
ther
hea
lth in
sura
nce.
SEND
PRO
OF
SEND
PRO
OF
SEND
PRO
OF
Mon
th
Day
Yea
r
1.M
onth
lyh
ousi
ngp
aym
ents
uch
as re
nt o
r mor
tgag
e, in
clud
ing
prop
erty
taxe
s(ju
sty
ours
hare
).$
____
____
____
____
___
2.If
you
pay
forw
ater
sep
arat
ely
how
muc
hdo
you
pay
?$
____
____
____
____
H
owo
ften
doy
oup
ay?
eve
rym
onth
2
tim
esa
yea
r
q
uart
erly
(4ti
mes
ay
ear)
o
nce
aye
ar
3.D
oyo
ure
ceiv
efr
eeh
ousi
nga
spa
rto
fyou
rpay
?
N
o
Yes
1.A
rey
ou,o
rany
one
who
live
sw
ithy
ou,a
ndis
app
lyin
g,in
are
side
ntia
ltre
atm
entf
acili
tyo
rrec
eivi
ngn
ursi
ng h
ome
care
ina
hos
pita
l,nu
rsin
gho
me
oro
ther
med
ical
inst
itutio
n?
No
Y
es
Ifye
s,fin
ish
com
plet
ing
this
app
licat
ion
AND
com
plet
eSu
pple
men
tA.
2.A
rey
ouo
rany
one
who
live
sw
ithy
oub
lind,
dis
able
dor
chro
nica
llyil
l?
No
Y
es
Ifye
s,fin
ish
com
plet
ing
this
app
licat
ion
AND
com
plet
eSu
pple
men
tA.
Not
e:I
fyou
are
app
lyin
gfo
rthe
Med
icar
eSa
ving
sPr
ogra
mo
nly
(MSP
),go
toS
ectio
nG.
You
do
notn
eed
toco
mpl
ete
Supp
lem
entA
.
If no
one
app
lyin
g is
Blin
d, D
isab
led,
Chr
onic
ally
Ill o
r in
a N
ursi
ng H
ome
pl
ease
go
to S
ectio
n G.
STO
P
DOH-4220-I3/15Page11
SEC
TIO
N E
H
ousi
ng E
xpen
ses
SEC
TIO
N D
H
ealt
h In
sura
nce
SEC
TIO
N F
B
lind,
Dis
able
d, C
hron
ical
ly Il
l or N
ursi
ng H
ome
Care
Th
ese
ques
tions
hel
p us
det
erm
ine
whi
ch p
rogr
am is
bes
t for
the
appl
ican
ts.
1.D
oes
anyo
nea
pply
ing
have
pai
dor
unp
aid
med
ical
orp
resc
riptio
nbi
llsfo
rthi
sm
onth
ort
heth
ree
mon
ths
befo
reth
ism
onth
?M
edic
aid
may
be
able
top
ayth
ese
bills
orr
eim
burs
eyo
u.
N
o
Yes
If
yes:
Nam
e:_
____
____
____
____
____
____
____
____
____
____
____
____
__
In
whi
chm
onth
(s)o
fthe
pre
viou
sth
ree
mon
ths
doy
ouh
ave
med
ical
bill
s?_
____
____
____
____
____
____
____
____
of
inco
me
for a
ny m
onth
in th
e th
ree-
mon
th p
erio
d fo
r whi
ch y
ou h
ave
bills
. If y
ou h
ave
paid
med
ical
bill
s for
whi
ch y
ou a
re s
eeki
ng re
imbu
rsem
ent,
you
mus
t sen
d co
pies
and
pro
of o
f pay
men
t.
2.D
oyo
u,o
rany
one
appl
ying
,hav
ean
yun
paid
med
ical
orp
resc
riptio
nbi
llso
lder
than
the
prev
ious
thre
em
onth
s?
N
o
Ye
s
3.H
ave
you,
ora
nyon
ew
holi
ves
with
you
and
isa
pply
ing,
mov
edin
toth
isco
unty
from
ano
ther
sta
teo
rNew
Yor
kSt
ate
coun
tyw
ithin
the
past
thre
em
onth
s?
N
o
Ye
s
Ifye
s,w
ho?
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Whi
chs
tate
?__
____
____
____
____
____
____
____
____
____
__
Whi
chco
unty
?__
____
____
____
____
____
____
____
____
4.D
oes
anyo
new
hois
app
lyin
gha
vea
pen
ding
law
suit
due
toa
nin
jury
?
N
o
Ye
s
Ifye
s,w
ho:
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
5.D
oes
anyo
nea
pply
ing
have
aW
orke
rs’C
ompe
nsat
ion
case
ora
nin
jury
,illn
ess,
ord
isab
ility
that
was
caus
edb
yso
meo
nee
lse
(that
coul
dbe
cove
red
byin
sura
nce)
?
N
o
Yes
Ifye
s,w
ho?
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
1.I
sth
esp
ouse
orp
aren
tofa
nyon
eap
plyi
ngd
ecea
sed?
N
o
Yes
Ifye
s,na
me
ofa
pplic
antw
ithd
ecea
sed
pare
nto
rspo
use
:__
____
____
____
____
____
____
____
____
____
____
(Ifs
pous
eor
par
enti
sde
ceas
edg
oto
que
stio
n3.
)
2.D
oes
apa
rent
ofa
nya
pply
ing
child
live
out
side
the
hom
e?(I
fno,
ski
pto
que
stio
n3)
N
oY
es
SEND
PRO
OF
Child
’s N
ame:
N
ame
of p
aren
t liv
ing
outs
ide
the
hom
e
Date
ofB
irth
(ifk
now
n):
____
__/_
____
_/__
____
Curr
ent o
r las
t kno
wn
addr
ess:
Stre
et:
C
ity/S
tate
:
SSN
(ifk
now
n):
Child
’s N
ame:
N
ame
of p
aren
t liv
ing
outs
ide
the
hom
e
Date
ofB
irth
(ifk
now
n):
____
__/_
____
_/__
____
Curr
ent o
r las
t kno
wn
addr
ess:
Stre
et:
C
ity/S
tate
:
SSN
(ifk
now
n):
3.I
san
yone
app
lyin
gst
illm
arrie
dto
som
eone
who
live
sou
tsid
eth
eho
me?
N
o
Yes
If
yes,
nam
eof
per
son
appl
ying
who
iss
tillm
arrie
d:_
____
____
____
____
____
____
____
____
____
____
___
Ifyo
ufe
arp
hysi
calo
rem
otio
nalh
arm
ify
oup
rovi
dein
form
atio
nab
outa
spo
use
who
doe
sno
tliv
ein
the
hom
e,ch
eck
this
box
Lega
l nam
e of
spou
se li
ving
out
side
of t
he h
ome:
D
ate
of B
irth
(if k
now
n):
_
____
_/__
____
/___
___
Curr
ent o
r las
t kno
wn
addr
ess:
Stre
et:
C
ity/S
tate
:
SSN
(ifk
now
n):
Ifyo
ufe
arp
hysi
calo
rem
otio
nalh
arm
ify
oup
rovi
dein
form
atio
nab
outa
par
entw
hod
oes
notl
ive
inth
eho
me,
chec
kth
isb
ox
DOH-4220-I3/15Page12
SEC
TIO
N G
A
ddit
iona
l Hea
lth
Que
stio
ns
SEC
TIO
N H
Pa
rent
or S
pous
e N
ot L
ivin
g
in th
e H
ouse
hold
or D
ecea
sed
Fam
ilies
who
are
app
lyin
gfo
rthe
irch
ildre
nan
dpr
egna
ntw
omen
are
NOT
requ
ired
tofi
llou
tthi
ssec
tion.
All
othe
rpeo
ple
who
are
app
lyin
gan
dar
eag
e21
oro
ver
mus
tbe
will
ing
top
rovi
dein
form
atio
nab
outa
par
ento
fan
appl
ying
min
oro
rasp
ouse
livi
ngo
utsi
deth
eho
me
tob
eel
igib
lefo
rhea
lthin
sura
nce,
unl
esst
here
is
good
caus
e.C
hild
ren
may
still
be
elig
ible
eve
nif
apa
rent
isn
otw
illin
gto
pro
vide
this
info
rmat
ion.
Ify
oufe
arp
hysi
calo
rem
otio
nalh
arm
asa
resu
ltof
pro
vidi
ng
info
rmat
ion
abou
tap
aren
tors
pous
eno
tliv
ing
inth
eho
me,
you
may
be
excu
sed
from
pro
vidi
ngth
isin
form
atio
n.T
hisi
scal
led
Good
Cau
se.Y
oum
ayb
eas
ked
to
show
that
you
hav
ea
good
reas
onfo
ryou
rfea
rs.
IMPO
RTAN
T: M
ostp
eopl
ew
ithM
edic
aid
mus
tcho
ose
ahe
alth
pla
n;if
you
don
’tch
oose
ah
ealth
pla
nyo
um
ayb
eau
tom
atic
ally
enr
olle
din
one
unl
ess
itis
det
erm
ined
you
are
exe
mpt
. If
you
need
info
rmat
ion
abou
twha
tpl
ans
are
avai
labl
ein
you
rcou
nty,
wha
tpla
nsy
ourd
octo
ris
ina
ndif
you
hav
eto
join
,ple
ase
call
New
Yor
k M
edic
aid
CHOI
CEa
t1-8
00-5
05-5
678.
You
can
also
call
orv
isit
your
loca
lDep
artm
ento
fSoc
ialS
ervi
ces.
Ify
ou
alre
ady
know
wha
tpla
nyo
uw
ant,
use
this
sec
tion
fory
ourp
lan
choi
ce.
NOT
E:If
you
orf
amily
mem
bers
are
foun
del
igib
lefo
rMed
icai
d,y
ouw
illb
een
rolle
din
the
heal
thp
lan
you
choo
seif
itp
rovi
des
Med
icai
d.If
you
live
ina
coun
tyth
atd
oes
notr
equi
rep
eopl
eon
Med
icai
dto
join
ah
ealth
pla
n,
you
can
tell
usy
oud
ono
twan
tto
bein
ah
ealth
pla
nby
calli
ngo
rwrit
ing
toy
ourl
ocal
Dep
artm
ento
fSoc
ialS
ervi
ces
orb
ych
ecki
ngth
isb
ox
If yo
u ar
e in
rece
ipt o
f Med
icar
e,
sk
ip th
is s
ectio
n.
Lega
l Las
t N
ame
Lega
l Fir
st N
ame
Date
of B
irth
Soci
al S
ecur
ity #
Nam
e of
Hea
lth P
lan
Yo
u ar
e En
rolli
ng in
Pref
erre
d Do
ctor
or
Hea
lth C
ente
r (op
tiona
l)
Chec
k Bo
x if
Your
Cur
rent
Pro
vide
rOB
/GYN
(opt
iona
l)
Iagr
eeto
hav
eth
ein
form
atio
non
this
app
licat
ion
and
onth
ean
nual
rene
wal
sha
red
only
am
ong
Med
icai
d,th
ehe
alth
pla
nsin
dica
ted
inS
ectio
nI,
the
loca
lsoc
ials
ervi
ces
dist
rict,
and
the
faci
litat
ede
nrol
lmen
tor
gani
zatio
npr
ovid
ing
the
appl
icat
ion
assi
stan
ce.I
als
oco
nsen
tto
shar
ing
this
info
rmat
ion
with
any
sch
ool-b
ased
hea
lthce
nter
that
pro
vide
sse
rvic
esto
the
appl
ican
t(s).
Iund
erst
and
this
info
rmat
ion
isb
eing
sh
ared
fort
hep
urpo
seo
fdet
erm
inin
gth
eel
igib
ility
oft
hose
indi
vidu
als
appl
ying
forM
edic
aid,
ort
oev
alua
teth
esu
cces
sof
thes
epr
ogra
ms.
Each
app
lyin
gad
ultm
usts
ign
this
app
licat
ion
inth
esp
ace
belo
w.
I hav
e re
ad a
nd u
nder
stan
d th
e Te
rms,
Rig
hts a
nd R
espo
nsib
ilitie
s inc
lude
d in
this
app
licat
ion
book
let o
n th
e ne
xt p
age.
Ice
rtify
und
erp
enal
tyo
fper
jury
that
eve
ryth
ing
onth
isa
pplic
atio
nis
the
trut
has
be
stI
know
.
Date
Si
gnat
ure
of a
dult
appl
ican
t or
aut
horiz
ed r
epre
sent
ativ
e fo
r th
e ap
plic
ant
Date
Si
gnat
ure
of a
dult
appl
ican
t or
aut
horiz
ed r
epre
sent
ativ
e fo
r th
e ap
plic
ant
STO
P
DOH-4220-I3/15Page13
SEC
TIO
N I
H
ealt
h Pl
an S
elec
tion
SEC
TIO
N J
S
igna
ture
TERMS, RIGHTS AND RESPONSIBILITIES
Bycompletingandsigningthisapplication,IamapplyingforMedicaid.Iunderstandthatthisapplication,noticesandothersupportinginformationwillbesenttotheprogram(s)forwhichIwanttoapply.Iagreetothereleaseofpersonalandfinancialinformationfromthisapplicationandanyotherinformationneededtodetermineeligibilityfortheseprograms.IunderstandthatImaybeaskedformoreinformation.Iagreetoimmediatelyreportanychangestotheinformationonthisapplication.
• IunderstandthatImustprovidetheinformationneededtoprovemyeligibilityforeachprogram.IfIhavebeenunabletogettheinformationforMedicaid,Iwilltellthesocialservicesdistrict.Thesocialservicesdistrictmaybeabletohelpingettingtheinformation.
• IfIamapplyingataplaceotherthanalocaldepartmentofsocialservices,andmychildrenarenotfoundeligibleforMedicaidusingthisapplication,IcancontactthelocaldepartmentofsocialservicestoseeifmychildrenareeligibleforMedicaidonsomeotherbasis.
• IunderstandthatworkersfromtheprogramsforwhichfamilymembersorIhaveappliedmaychecktheinformationgivenbymeforthisapplication.Theagenciesthatruntheseprogramswillkeepthisinformationconfidentialaccordingto42U.S.C.1396a(a)(7)and42CFR431.300-431.307,andanyfederalandstatelawsandregulations.
• IunderstandthatMedicaid,willnotpaymedicalexpensesthatinsuranceoranotherpersonissupposedtopay,andthatifIamapplyingforMedicaid,Iamgivingtotheagencyallofmyrightstopursueandreceivemedicalsupportfromaspouseorparentsofpersonsunder21yearsoldandmyrighttopursueandreceivethirdpartypaymentsfortheentiretimeIaminreceiptofbenefits.
• IwillfileanyclaimsforhealthoraccidentinsurancebenefitsoranyotherresourcestowhichIamentitled.IunderstandthatIhavetherighttoclaimgoodcausenottocooperateinusinghealthinsuranceifitsusecouldcauseharmtomyhealthorsafetyortothehealthandsafetyofsomeoneIamlegallyresponsiblefor.
• IunderstandthatmyeligibilityforMedicaidwillnotbeaffectedbymyrace,color,ornationalorigin.Ialsounderstandthatdependingontherequirementsoftheprogram,myage,sex,disabilityorcitizenshipstatusmaybeafactorinwhetherornotIameligible.
• IunderstandthatifmychildisonMedicaid,heorshecangetcomprehensiveprimaryandpreventivecare,includingallnecessarytreatmentthroughtheChild/TeenHealthProgram.Icangetmoreinformationonthisprogramfromthelocaldepartmentofsocialservices.
• Iunderstandthatanyonewhoknowinglyliesorhidesthetruthinordertoreceiveservicesundertheseprogramsiscommittingacrimeandsubjecttofederalandstatepenaltiesandmayhavetorepaytheamountofbenefitsreceivedandpaycivilpenalties.TheNewYorkStateDepartmentofTaxandFinancehastherighttoreviewincomeinformationonthisform.
SOCIAL SECURITY NUMBER
SSNsarerequiredforallapplicants,unlessthepersonispregnantoranon-qualifiedalien.SSNsarenotrequiredformembersofmyhouseholdwhoarenotapplyingforbenefitsunlessthepersonismyspouseandmyeligibilitydependsontheamountofresourcesownedbymyspouse.IunderstandthatthisisrequiredbyFederalLawat42U.S.C.1320b-7(a)andbyMedicaidregulationsat42CFR435.910.SSNsareusedinmanyways,bothwithindepartmentofsocialservices(DSS)andbetweentheDSSandfederal,state,andlocalagencies,bothinNewYorkandotherjurisdictions.SomeusesofSSNsare:tocheckidentity,toidentifyandverifyearnedandunearnedincome,toseeifnon-custodialparentscangethealthinsurancecoverageforapplicants,toseeifapplicantscangetmedicalsupport,toseeifapplicantscangetmoneyorotherhelp,andtoverifyresourceswithfinancialinstitutionsforapplicantsandtheirnon-applyingspouse.SSNsmayalsobeusedforidentificationoftherecipientwithinandbetweencentralgovernmentalMedicaidagenciestoinsureproperservicesaremadeavailabletotherecipient.Also,ifIapplyforotherprogramsinthisjointapplication,thoseprogramswillhaveaccesstomySSNandcoulduseitintheadministrationoftheprogram.
FOR MEDICAID APPLICANTS ONLY
• ReleaseofEducationalRecordsIgivepermissiontothelocaldepartmentofsocialservicesandNewYorkStatetoobtainanyinformationregardingtheeducationalrecordsofmychild(ren),hereinnamed,necessaryforclaimingMedicaidreimbursementsforhealth-relatededucationalservices,andtoprovidetheappropriatefederalgovernmentagencyaccesstothisinformationforthesolepurposeofaudit.
• EarlyInterventionProgramIfmychildisevaluatedfororparticipatesintheNewYorkStateEarlyInterventionProgram,IgivepermissiontothelocaldepartmentofsocialservicesandNewYorkStatetosharemychild’sMedicaideligibilityinformationwithmycountyEarlyInterventionProgramforthepurposeofbillingMedicaid.
• ReimbursementofMedicalExpensesIunderstandthatIhavearightaspartofmyMedicaidapplication,orlater,torequestreimbursementofexpensesIpaidforcoveredmedicalcare,servicesandsuppliesreceivedduringthethreemonthperiodpriortothemonthofmyapplication.Afterthedateofmyapplication,reimbursementofcoveredmedicalcare,servicesandsupplieswillonlybeavailableifobtainedfromMedicaidenrolledproviders.
MEDICAID MANAGED CARE
IhavereadhowtofindoutwhethermycountyrequiresMedicaidenrolleestojoinahealthplan,andhowtofindoutwhathealthplansareavailabletomeinMedicaidmanagedcare.I/wealsounderstandthatifI/wearefoundeligibleforMedicaidandI/weareinacountythatrequiresMedicaidenrolleestobeinamanagedcarehealthplan,I/wewillbeenrolledinthehealthplanI/wechoseunlessthathealthplandoesnotparticipateinMedicaidmanagedcare.
DOH-4220-I3/15Page14
IfI/weareinacountythatdoesnotrequireenrolleestobeinaMedicaidmanagedcarehealthplan,I/wewillstillbeenrolledinthehealthplanI/wechoseunlessI/wenotifymylocalsocialservicesdepartmentinwriting,orI/wechecktheboxinSectionI,thatI/wedonotwanttobeinthatplan.
IhavereadhowtofindouttherightsandbenefitsthatIwillhaveasamemberofamanagedcarehealthplanandthebenefitlimitationsofmanagedcaremembership.IunderstandthatinMedicaidmanagedcare,ImustchooseaPrimaryCareProvider(PCP)andthatIwillhaveachoicefromatleastthreePCPsinmyhealthplan.IunderstandthatonceIenrollinahealthplan,IwillhavetousemyPCPandotherprovidersinmyhealthplanexceptinafewspecialcircumstances.
IunderstandthatifachildisborntomewhileIamamemberofaMedicaidmanagedcarehealthplan,mychildwillbeenrolledinthesamehealthplanthatIamin.IunderstandthatifachildisborntomewhileIamamemberofaMedicaidmanagedcare,mychildwillbeenrolledinthesamehealthplanthatIamin.
• ReleaseofMedicalInformationIconsenttothereleaseofanymedicalinformationaboutmeandanymembersofmyfamilyforwhomIcangiveconsent:
•BymyPCP,anyotherhealthcareproviderortheNewYorkStateDepartmentofHealth(NYSDOH)tomyhealthplanandanyhealthcareprovidersinvolvedincaringformeormyfamily,asreasonablynecessaryformyhealthplanormyproviderstocarryouttreatment,payment,orhealthcareoperations.Thismayincludepharmacyandothermedicalclaimsinformationneededtohelpmanagemycare;
•BymyhealthplanandanyhealthcareproviderstoNYSDOHandotherauthorizedfederal,state,andlocalagenciesforpurposesofadministrationoftheMedicaidprograms;and
•Bymyhealthplantootherpersonsororganizations,asreasonablynecessaryformyhealthplantocarryouttreatment,payment,orhealthcareoperations.
Ialsoagreethattheinformationreleasedfortreatment,paymentandhealthcareoperationsmayincludeHIV,mentalhealthoralcoholandsubstanceabuseinformationaboutmeandmembersofmyfamilytotheextentpermittedbylaw,untilIrevokethisconsent.
IfmorethanoneadultinthefamilyisjoiningaMedicaidhealthplan,thesignatureofeachadultapplyingisnecessaryforconsenttoreleaseinformation.
TERMS, RIGHTS AND RESPONSIBILITIES
FOR OFFICE USE ONLY
To be completed by the person assisting with the application
SignatureofPersonWhoObtainedEligibilityInformation:
X
EmployedBy:(checkone)
HealthPlan SocialServicesDistrict ProviderAgency QualifiedEntities
EmployerName:
To be used by the local Social Services District
EligibilityDeterminedBy: Date: EligibilityApprovedBy: Date:
CenterOffice: ApplicationDate: UnitID: WorkerID:
CaseName: District: CaseType: Case#:
EffectiveDate: MADispositionReasonCode:
DenialCode Withdrawal
Proxy:
Yes No
Registry#: Ver:
DOH-4220-I3/15Page15