It must also be completed if anyone is not certified disabled but chronically ill, or institutionalized and applying for coverage of nursing home care.
Sections A to F: Sections A through F must be completed and this Supplement must be signed.
Nursing home care: If you or anyone in your household is applying for coverage of nursing home care, you must also complete sections G through I.
Medicare Savings Program: If you are applying for the Medicare Savings Program (MSP) only, this Supplement does not need to be completed.
Resources: If you are applying for coverage of community-based long-term care services, you must submit documentation of the current amount of your resources.
Changes: You must report any changes in this information within 10 days of the change.
| Question | Answer |
|---|---|
| Form Name | DOH-4495A |
| Form Length | 6 pages |
| Fillable? | Yes |
| Fillable fields | 312 |
| Avg. time to fill out | 52 min |
| Edition | 2/10 |
| Other names | DOH-4495A, DOH 4495A, 4495A, Supplement A, Access NY Supplement A, Medicaid Supplement A, DOH-4495A form |
| Official source | DOH-4495A (Rev 2/10), |
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