ACCESS NY HEALTH CARE Medicaid

Print clearly in blue or black ink. An incomplete application cannot be processed and will result in a delay of a decision on your application.

SECTION A Applicant’s Information Please tell us who you are and how to contact you.
Legal First Name Middle Initial Legal Last Name

Primary Phone # Home Cell Another Phone # Home Cell What Language Do You: Speak?
Work Other Work Other Read?
HOME ADDRESS of the persons applying for health insurance Street Apt.#
SEND PROOF
City State Zip Code County
Check here if homeless
MAILING ADDRESS of the persons applying for health insurance Street Apt.#
if different from above.
City State Zip Code

OPTIONAL: If there is another person you would like to receive your Name State
Medicaid notices, please provide this person’s contact information.
I want this contact person to: Street Apt.# Zip Code
Apply for and/or renew Medicaid for me
Check all Discuss my Medicaid application or case, if needed City
that apply Phone # Home Cell
Get notices and correspondence Work Other

Important Notice
Options Available to Applicants Who May Be Blind or Visually Impaired
If you are blind or visually impaired and require information in an alternative format, check the type of
mail you want to receive from us.
Standard notice and large print notice
Standard notice and data CD notice
Standard notice and audio CD notice
Standard notice and braille notice, if you assert that none of the other alternative formats
will be equally effective for you
If you require another accommodation, please contact your social services district.
APPLICATIONS FOR BENEFITS ADMINISTERED BY THE NEW YORK STATE MEDICAID PROGRAM (INCLUDING THE MEDICARE SAVINGS PROGRAM
AND THE FAMILY PLANNING BENEFIT PROGRAM) ARE AVAILABLE IN LARGE PRINT AND DATA FORMATS. AUDIO AND BRAILLE VERSIONS OF THE
APPLICATIONS ARE AVAILABLE FOR INFORMATIONAL PURPOSES ONLY.
DOH-4220 (1/23) page 1 of 10
 If you live in the household, start with yourself. If you do not, start with any adults who live in the household. List the full legal
names of the persons applying for or already receiving Medicaid and list the ID Number from their Benefit Card or health plan ID
card. You must provide information for family members including: parents, step-parents, and spouses. You may provide
information for other family members (for example, a dependent child under the age of 21). Listing other family members may
SECTION B Family Information allow us to give you a higher eligibility level. Applicants who are pregnant or under age 19 may be eligible for insurance
regardless of immigration status. New York State ensures your right to access State benefits and/or services regardless of your
sex, gender identity, or expression. If you would like to provide us with how you or your household members currently identify,
please also select gender identity.
If this person ††
Received
Is this
Date of has or had public Social Please mark one box a service
Is this person the What is the
Birth person parent relationship health coverage Security that indicates your from the
SENDPROOF
SEND PROOF *Gender applying Is this of an to the in the past, Number current Citizenship or IHS, or other
Identity for health person applying person check the box (if you Immigration Status. Race/ Ethnic Indian Health
Sex (optional) insurance? pregnant? child? in Box 1? that applies. have one) SEND
SEND PROOF
PROOF Group (Optional) Program?

__/__/____ Male Yes Yes Yes SELF Child Health U.S. Citizen B - Black or African-
American
Yes
Plus Immigrant/non-citizen
Female No No No
Medicaid
I - American Indian or
Alaska Native
No
Legal First, Middle, Last Name Male Non-Binary/ What Family Health Enter the date you received W - White
Non-Conforming is the Plus your immigration status U- Unknown
Female **A- Asian
X due date? ID Number from _____/_____/________ **U- Native Hawaiian or
X
1 This person’s birth name before they were married Transgender __/__/__ Benefit Card/Plan MM DD YYYY †
Other AAPI
other Pacific Islander
Card, if known:
Different Identity Non-immigrant _________________
City Describe your (Visa holder)
Please also tell us if you are
identity (optional). None of the above Hispanic or Latino
H-Hispanic or Latino
State of Birth Country of Birth
__/__/____ Male Yes Yes Yes Child Health U.S. Citizen B - Black or African-
American
Yes
Plus Immigrant/non-citizen
Female No No No
Medicaid
I - American Indian or
Alaska Native
No
Legal First, Middle, Last Name Male Non-Binary/ What Family Health Enter the date you received W - White
Non-Conforming is the Plus your immigration status U- Unknown
Female **A- Asian
X due date? ID Number from _____/_____/________ **U- Native Hawaiian or
X
2 This person’s birth name before they were married Transgender __/__/__ Benefit Card/Plan MM DD YYYY †
Other AAPI
other Pacific Islander
Card, if known:
Different Identity Non-immigrant _________________
City Describe your (Visa holder)
Please also tell us if you are
identity (optional). None of the above Hispanic or Latino
H-Hispanic or Latino
State of Birth Country of Birth

SEND PROOF Refer to the “Documents Needed When You Apply for Health Insurance” on pages 4-6, for a list of documents that prove Identity, Citizenship or Immigration Status.
Gender Identity: Gender identity is how you perceive yourself and what you call yourself. Your gender identity can be the same as or different from your sex.
*

**
If you have selected A- Asian, or P- Native Hawaiian or Pacific Islander plese see below information on Other AAPI.
†
Other Asian American/Pacific Islander (optional) - Please identify your AAPI subgroup. Subgroups within this community include, but are not limited to: Chinese, Japanese, Filipino, Korean, Vietnamese, Cambodian, Indonesian,
Pakistani, Sri Lankan, Taiwanese, Native Hawaiian, Samoan, Tongan, Guamanian or Chamorro, Marshallese, Fijian, and other.
††
Have you ever received a service from the Indian Health Service (IHS), a Tribal Health Program, an Urban Indian Health Program or through a referral from IHS or one of these programs?

DOH-4220 (1/23) page 2 of 10

 SECTION B Family Information Continued from previous page
If this person ††
Received
Is this
Date of has or had public Social Please mark one box a service
Is this person the What is the
Birth person parent relationship health coverage Security that indicates your from the
SEND PROOF
SEND PROOF *Gender applying Is this of an to the in the past, Number current Citizenship or IHS, or other
Identity for health person applying person check the box (if you Immigration Status. Race/ Ethnic Indian Health
Sex (optional) insurance? pregnant? child? in Box 1? that applies. have one) SEND
SEND PROOF
PROOF Group (Optional) Program?

__/__/____ Male Yes Yes Yes SELF Child Health U.S. Citizen B - Black or African-
American
Yes
Plus Immigrant/non-citizen
Female No No No
Medicaid
I - American Indian or
Alaska Native
No
Legal First, Middle, Last Name Male Non-Binary/ What Family Health Enter the date you received W - White
Non-Conforming is the Plus your immigration status U- Unknown
Female **A- Asian
X due date? ID Number from _____/_____/________ **U- Native Hawaiian or
X
3 This person’s birth name before they were married Transgender __/__/__ Benefit Card/Plan MM DD YYYY †
Other AAPI
other Pacific Islander
Card, if known:
Different Identity Non-immigrant _________________
City Describe your (Visa holder)
Please also tell us if you are
identity (optional). None of the above Hispanic or Latino
H-Hispanic or Latino
State of Birth Country of Birth
__/__/____ Male Yes Yes Yes Child Health U.S. Citizen B - Black or African-
American
Yes
Plus Immigrant/non-citizen
Female No No No
Medicaid
I - American Indian or
Alaska Native
No
Legal First, Middle, Last Name Male Non-Binary/ What Family Health Enter the date you received W - White
Non-Conforming is the Plus your immigration status U- Unknown
Female **A- Asian
X due date? ID Number from _____/_____/________ **U- Native Hawaiian or
X
4 This person’s birth name before they were married Transgender __/__/__ Benefit Card/Plan MM DD YYYY †
Other AAPI
other Pacific Islander
Card, if known:
Different Identity Non-immigrant _________________
City Describe your (Visa holder)
Please also tell us if you are
identity (optional). None of the above Hispanic or Latino
H-Hispanic or Latino
State of Birth Country of Birth
__/__/____ Male Yes Yes Yes Child Health U.S. Citizen B - Black or African-
American
Yes
Plus Immigrant/non-citizen
Female No No No
Medicaid
I - American Indian or
Alaska Native
No
Legal First, Middle, Last Name Male Non-Binary/ What Family Health Enter the date you received W - White
Non-Conforming is the Plus your immigration status U- Unknown
Female **A- Asian
X due date? ID Number from _____/_____/________ **U- Native Hawaiian or
X
5 This person’s birth name before they were married Transgender __/__/__ Benefit Card/Plan MM DD YYYY †
Other AAPI
other Pacific Islander
Card, if known:
Different Identity Non-immigrant _________________
City Describe your (Visa holder)
Please also tell us if you are
identity (optional). None of the above Hispanic or Latino
H-Hispanic or Latino
State of Birth Country of Birth

Is anyone in your household a veteran? Yes No If yes, name:_________________________________________________________________________________________________

SEND PROOF Refer to the “Documents Needed When You Apply for Health Insurance” on pages 4-6, for a list of documents that prove Identity, Citizenship or Immigration Status.
Gender Identity: Gender identity is how you perceive yourself and what you call yourself. Your gender identity can be the same as or different from your sex.
*

**
If you have selected A- Asian, or P- Native Hawaiian or Pacific Islander plese see below information on Other AAPI.
†
Other Asian American/Pacific Islander (optional) - Please identify your AAPI subgroup. Subgroups within this community include, but are not limited to: Chinese, Japanese, Filipino, Korean, Vietnamese, Cambodian, Indonesian,
Pakistani, Sri Lankan, Taiwanese, Native Hawaiian, Samoan, Tongan, Guamanian or Chamorro, Marshallese, Fijian, and other.
††
Have you ever received a service from the Indian Health Service (IHS), a Tribal Health Program, an Urban Indian Health Program or through a referral from IHS or one of these programs?

DOH-4220 (1/23) page 3 of 10

 SECTION C Family Income Write the types of money and the amount received by everyone listed in Section B and SEND PROOF
SEND PROOF

Earnings from Work: Includes wages, salaries, commissions, tips, overtime, self-employment. If you are self-employed, check here: If no earnings from work, check here:
Name of Person Type of Income/Employer Name How Much? (before taxes) How Often? (weekly, monthly)

Unearned Income: Includes Social Security Benefits, disability payments, unemployment payments, interest and dividends, veterans’ benefits, Workers’ Compensation, child support payments/alimony, rental income,
pension, annuities and trust income. If no unearned income, check here:
Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

Contributions: Money from relations or friends, roomers or boarders (include money that anyone gives you each month to help meet living expenses). If no contributions, check here:
Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

Other: Temporary (cash) Assistance, Supplemental Security Income (SSI) payments, student grants, or loans. If none, check here:
Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

If you or any applying adult in Section B does not have income, tell us who?
1. If there is no income listed above, please explain how you are living: (For example: living with friend or relative)
2. Have you or anyone who is applying changed jobs or stopped working in the last 3 months? No Yes
If yes: Your last job was: Date / / Name of Employer:
3. Are you or anyone who is applying a student in a vocational, undergraduate, or graduate program? No Yes
If yes: Full Time Part Time Undergraduate Graduate Name of Student: ______________________
4. Do you have to pay for childcare (or for the care of a disabled adult) in order to work or go to school? No Yes
Child’s/Adult’s Name: How Much? $ How Often? (weekly, every two weeks, monthly)
Child’s/Adult’s Name: How Much? $ How Often? (weekly, every two weeks, monthly)
Child’s/Adult’s Name: How Much? $ How Often? (weekly, every two weeks, monthly)

5. If you are not eligible for Medicaid coverage, you may still be eligible for the Family Planning Benefit Program. Are you interested in receiving coverage for Family Planning Services only? No Yes
6. Are you or your spouse / other parent required to pay court ordered support? No Yes Who How Much? $

DOH-4220 (1/23) page 4 of 10

 SECTION D Health Insurance You and your family may still be eligible even if you have other health insurance.

1. Does anyone who is applying have Medicare? No Yes If yes, include a copy of your card (red, white and blue card), for each Medicare beneficiary. Complete the rest of this application
SEND PROOF and complete Supplement A.
If no, and you have Chronic Renal Failure (End Stage Renal Disease/ESRD) or Amyotrophic Lateral Sclerosis (ALS),or you are 65
years of age or older, or turning age 65 within three months, and do not have Medicare, you must apply for Medicare and show
proof of application. Some people are required to apply for MEDICARE as a condition of eligibility for Medicaid.
Please reference pages 2 and 3 ( Section D ) for additional information regarding eligibility requirements.
Note: If you are applying for the Medicare Savings Program (MSP) only, go to Section G. You do NOT need to complete Supplement A.

2. Does anyone who is applying already have other commercial No Yes If yes, you must send a copy of the front and back of the insurance card with this application.
health insurance, including long term care insurance?
SEND PROOF
Name of Insured (primary): Persons Covered:

Cost of Policy: End date of coverage, if ending soon / /

Month Day Year

3. Does your current job offer health insurance? No Yes If yes, a “Request for Information Employer Sponsored Health Insurance” form will be sent to you.
We may be able to help pay for it.

SECTION E Housing Expenses

1. Monthly housing payment such as rent or mortgage, including property taxes (just your share) $

2. If you pay for water separately how much do you pay? $ SEND PROOF

How often do you pay? every month 2 times a year quarterly (4 times a year) once a year

3. Do you receive free housing as part of your pay? No Yes

SECTION F Blind, Disabled, Chronically Ill or Nursing Home Care These questions help us determine which program is best for the applicants.
If no one is Blind, Disabled, Chronically Ill or in a Nursing Home STOP please go to Section G.
1. Are you, or anyone who lives with you and is applying, in a No Yes If yes, finish completing this application AND complete Supplement A.
residential treatment facility or receiving nursing home care in
a hospital, nursing home or other medical institution?

2. Are you or anyone who lives with you blind, disabled or No Yes If yes, finish completing this application AND complete Supplement A.
chronically ill?

Note: If you are applying for the Medicare Savings Program only (MSP), go to Section G. You do not need to complete Supplement A.

DOH-4220 (1/23) page 5 of 10

 SECTION G Additional Health Questions
1. Does anyone applying have paid or unpaid medical or prescription bills for this No Yes If yes, name:
month or the three months before this month? Medicaid may be able to pay these
bills or reimburse you. In which month(s) of the previous three months do you have medical bills?
SENDPROOF
SEND PROOF of income for any month in the three-month period for which you have bills. If you have paid medical bills for which you are seeking reimbursement, you must send copies and proof of payment.

2. Do you, or anyone applying, have any unpaid medical or prescription bills older No Yes
than the previous three months?
3. Have you, or anyone who lives with you and is applying, moved into this county No Yes If yes, who?
from another state or New York State county within the past three months?
Which state?

Which county?

4. Does anyone who is applying have a pending lawsuit due to an injury? No Yes If yes, who?

5. Does anyone applying have a Workers’ Compensation case or an injury, illness, or No Yes If yes, who?
disability that was caused by someone else (that could be covered by insurance)?

Pregnant applicants and families who are applying only for their children are NOT required to fill out this section. All other people who are
Parent or Spouse applying and are age 21 or over must be willing to provide information about a parent of an applying minor or a spouse living outside the home to
SECTION H Not Living with the be eligible for health insurance, unless there is good cause. Children may still be eligible even if a parent is not willing to provide this information.
If you fear physical or emotional harm as a result of providing information about a parent or spouse not living in the home, you may be excused
Family or Deceased from providing this information. This is called Good Cause. You may be asked to show that you have a good reason for your fears.

1. Is the spouse or parent of anyone applying deceased? No Yes If yes, name of applicant with deceased parent or spouse
(If spouse or parent is deceased go to question 3.)
2. Does a parent of any applying child live outside the home? (If no, skip to question 3) No Yes
If you fear physical or emotional harm if you provide information about a parent who does not live in the home, check this box .

Child’s Name: Name of parent living outside the home Current or last known address:
Street: City/State:

Date of Birth (if known): / / SSN (if known):

Child’s Name: Name of parent living outside the home Current or last known address:

Street: City/State:

Date of Birth (if known): / / SSN (if known):

3. Is anyone applying still married to someone who lives outside the home? No Yes If yes, name of person applying who is still married:
If you fear physical or emotional harm if you provide information about a spouse who does not live in the home, check this box

Legal name of spouse living outside of the home: Current or last known address:

Street: City/State:

Date of Birth (if known): / / SSN (if known):

DOH-4220 (1/23) page 6 of 10

 SECTION I Health Plan Selection These questions help us determine which program is best for the applicants

If you are in receipt of Medicare, STOP skip this section.

IMPORTANT: Most people with Medicaid must choose a health plan; if you don’t choose a health plan you may be automatically enrolled in one unless it is determined you are exempt. If you need
information about what plans are available in your county, what plans your doctor is in and if you have to join, please call New York Medicaid CHOICE at 1-800-505-5678. You can also call or visit your
local department of social services. If you already know what plan you want, use this section for your plan choice.
NOTE: If you or family members are found eligible for Medicaid, you will be enrolled in the health plan you choose. If you are an American Indian/Alaska Native you are not required to join a health plan;
you can tell us you do not want to be in a health plan by calling or writing to your local department of social services or by checking this box .
Preferred Doctor
or Health Center (optional)
Name of Health Plan You are Check Box if Your Current
Legal Last Name Legal First Name Date of Birth Social Security # Enrolling in Provider OB/GYN (optional)

SECTION J Signature
I agree to have the information on this application and on the annual renewal shared only among Medicaid, the health plans indicated in Section I, the local department of social services, and the
organization providing the application assistance. I also consent to sharing this information with any school-based health center that provides services to the applicant(s). I understand this information is
being shared for the purpose of determining the eligibility of those individuals applying for Medicaid, or to evaluate the success of these programs. Each applying adult must sign this application in the
space below.
I have read and understand the Terms, Rights and Responsibilities included in this application booklet on the next page. I certify under penalty of perjury that everything on this application is the
truth as best I know.

Date Signature of adult applicant or authorized representative for the applicant

Date Signature of adult applicant or authorized representative for the applicant

Health Care Proxy

The New York Health Care Proxy Law allows you to choose someone you trust to make health care decisions for you if you can’t make them for yourself. This person is called a health care agent.
You can learn more about the New York State Health Care Proxy Law and get the form for a health care agent (proxy form) on the New York State Department of Health website at:
www.health.ny.gov/professionals/patients/health_care_proxy
To get a copy of the form mailed to you, call the New York State Medicaid Help Line at 1-800-541-2831.

DOH-4220 (1/23) page 7 of 10

 TERMS, RIGHTS AND RESPONSIBILITIES
By completing and signing this application, I am applying for Medicaid. I understand that this
application and other supporting information will be sent to the program(s) for which I want to Social Security Number (SSNs)
apply. I agree to the release of personal and financial information from this application and any
other information needed to determine eligibility for these programs. I understand that I may be SSNs are required for all applicants, unless the person is a non-qualified non-citizen. I understand
asked for more information. I agree to immediately report any changes to the information on this that this is required by Federal Law at 42 U.S.C. 1320b-7 (a) and by Medicaid regulations at 42 CFR
application. 435.910. SSNs are not required for members of my family who are not applying for benefits. If my
• I understand that I must provide the information needed to prove my eligibility for each eligibility depends on the amount of resources owned by my spouse, resources can be verified if my
program. If I have been unable to get the information for Medicaid, I will tell the local spouse’s SSN is provided. SSNs are used in many ways, both within local department of social
department of social services. The local department of social services may be able to help in services (DSS) and between the DSS and federal, state, and local agencies, both in New York and
getting the information. other jurisdictions. Some uses of SSNs are: to check identity, to identify and verify earned and
unearned income, to see if non-custodial parents can get health insurance coverage for their
• If I am applying at a place other than a local department of social services, and my children are child(ren), to see if applicants can get medical support, to see if applicants can get money or other
not found eligible for Medicaid using this application, I can contact the local department of help, and to verify resources for applicants and their non-applying spouse. SSNs may also be used
social services to see if my children are eligible for Medicaid on some other basis. for identification of the recipient within and between central governmental Medicaid agencies to
• I understand that workers from the programs, for which family members or I have applied, may insure proper services are made available to the recipient.
check the information given by me for this application. The agencies that run these programs
will keep this information confidential according to 42 U.S.C. 1396a (a) (7) and 42 CFR 431.300-
431.307, and any federal and state laws and regulations. For Medicaid Applicants Only
• I understand that Medicaid, will not pay medical expenses that insurance or another person is
• Release of Educational Records
supposed to pay, and that if I am applying for Medicaid, I am giving to the agency all of my rights to
I give permission to the local department of social services and New York State to obtain any
pursue and receive medical support from a spouse or parents of persons under 21 years old and
information regarding the educational records of my child(ren), herein named, necessary for
my right to pursue and receive third party payments for the entire time I am in receipt of benefits.
claiming Medicaid reimbursements for health-related educational services, and to provide the
• I will file any claims for health or accident insurance benefits or any other resources to which I appropriate federal government agency access to this information for the sole purpose of audit.
am entitled. I understand that I have the right to claim good cause not to cooperate in using
• Early Intervention Program
health insurance if its use could cause harm to my health or safety or to the health and safety of
If my child is evaluated for or participates in the New York State Early Intervention Program, I
someone I am legally responsible for.
give permission to the local department of social services and New York State to share my
• I understand that my eligibility for Medicaid will not be affected by my race, color, or national child’s Medicaid eligibility information with my county Early Intervention Program for the
origin. I also understand that depending on the requirements of the program, my age, disability purpose of billing Medicaid.
or citizenship status may be a factor in whether or not I am eligible.
• Reimbursement of Medical Expenses
• I understand that if my child is on Medicaid, they can get comprehensive primary and preventive I understand that I have a right as part of my Medicaid application, or later, to request
care, including all necessary treatment through the Child/Teen Health Program. I can get more reimbursement of expenses I paid for covered medical care, services and supplies received
information on this program from the local department of social services. during the three month period prior to the month of my application. After the date of my
• I understand that anyone who knowingly lies or hides the truth in order to receive services application and ending on the date I receive my Medicaid benefit card (Common Benefit
under these programs is committing a crime and subject to federal and state penalties and may Identification Card (CBIC)), I understand that reimbursement of medically necessary covered
have to repay the amount of benefits received and pay civil penalties. The New York State medical care, services and supplies will only be available if obtained from Medicaid enrolled
Department of Tax and Finance has the right to review income information on this form. providers and that reimbursement is limited to no more than the Medicaid rate or fee in effect at
the time of service, even if I paid more. I understand that once I receive my Medicaid (CBIC)
benefit card, I must visit only Medicaid enrolled providers or network providers of my Medicaid
managed care plan to obtain covered care and services, that my provider must submit a claim to
Medicaid or my Medicaid managed care plan to be paid for medically necessary services and
that no reimbursement will be made for expenses I incur after that date and pay for myself.

DOH-4220 (1/23) page 8 of 10

 Medicaid Managed Care Notice of Nondiscrimination Policy
I have read how to find out what Medicaid managed care health plans are available to me in my The New York Medicaid program complies with applicable Federal civil rights laws and state laws
county. I understand that if I, and any members of my family who are applying, are found eligible and does not discriminate on the basis of race, color, national origin, creed/religion, sex, age,
for Medicaid and are required to be in a managed care health plan, I and any eligible family marital/family status, disability, arrest record, criminal conviction(s), gender identity, sexual
members who applied, will be enrolled in the health plan I choose. orientation, predisposing genetic characteristics, military status, domestic violence victim status
I have read how to find out the rights and benefits that I will have as a member of a managed care and/or retaliation.
health plan and the benefit limitations of managed care membership. I understand that in If you believe that the New York Medicaid program has discriminated against you, you may file a
Medicaid managed care, I must choose a Primary Care Provider (PCP) and that I will have a choice complaint by going to: http://www.health.ny.gov/regulations/discrimination_complaints/ or, by
from at least three PCPs in my health plan. I understand that once I enroll in a health plan, I will emailing the Diversity Management Office at [email protected].
have to use my PCP and other providers in my health plan except in a few special circumstances. You may also file a civil rights complaint with the U.S. Department of Health and Human Services,
I understand that if a child is born to me while I am a member of a Medicaid managed care health Office for Civil Rights electronically at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or
plan, my child will be enrolled in the same health plan that I am in. phone at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room
Release of Medical Information 509F, HHH Building, Washington, D.C. 20201; 800-368-1019 (TTY 800-537-7697). Complaint forms
I consent to the release of any medical information about me and any members of my family for are available at https://www.hhs.gov/ocr/complaints/index.html.
whom I can give consent:
• By my PCP, any other health care provider or the New York State Department of Health Accommodations
(NYSDOH) to my health plan and any health care providers involved in caring for me or my
family, as reasonably necessary for my health plan or my providers to carry out treatment, The New York Medicaid program provides free aid and services to people with disabilities to
payment, or health care operations. This may include pharmacy and other medical claims communicate effectively with us,
information needed to help manage my care; such as:
• By my health plan and any health care providers to NYSDOH and other authorized federal, • TTY through NY Relay Service
state, and local agencies for purposes of administration of the Medicaid programs; and • If you are blind or seriously visually impaired and need notices or other written materials in
• By my health plan to other persons or organizations, as reasonably necessary for my health an alternative format (large print, audio, or data CD, or Braille), and you reside in a county
plan to carry out treatment, payment, or health care operations. outside of New York City, please call your local department of social services. If you reside in
the five boroughs of New York City, please call the Human Resources Administration’s Office
I also agree that the information released for treatment, payment and health care operations may of Constituent Services at 212-331-4640. Or tell us in Section A on page 1 of this application.
include HIV, mental health or alcohol and substance abuse information about me and members of
my family to the extent permitted by law, until I revoke this consent. The NY Medicaid Program also provides free language assistance services to people whose
primary language is not English such as:
If more than one adult in the family is joining a Medicaid health plan, the signature of each adult • Qualified interpreters
applying is necessary for consent to release information. • Written information in other languages
If you need these services or for more information on Reasonable Accommodations, and you reside
in a county outside of New York City, please call your local department of social services. If you
reside in the five boroughs of New York City, please call the Human Resources Administration’s
Office of Constituent Services at 212-331-4640.

DOH-4220 (1/23) page 9 of 10

 For Office Use Only
To be completed by the person assisting with the application
Signature of Person Who Obtained Eligibility Information: Employed By: (check one) Health Plan Local Department of Social Services Provider Agency Qualified Entities
X Employer Name:
To be used by the local social services district
Eligibility Determined By: Date: Eligibility Approved By: Date:
Center Office: Application Date: Unit ID: Worker ID:
Case Name: District: Case Type: Case #:
Effective Date: MA Disposition Reason Code Proxy: Registry #: Ver:
Denial Code Withdrawal Code No Yes

DOH-4220 (1/23) page 10 of 10