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Here is the details about the form you were in search of to fill out. It can tell you the amount of time you will require to finish doh 4328 msp application, what fields you need to fill in, etc.
Question | Answer |
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Form Name | Doh 4328 Msp Application |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | pdf medicare savings program, doh 4328 form, ny medicare savings, medicare savings application form |
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Health Insurance Programs
MEDICARE SAVINGS PROGRAM
APPLICATION
(Please Print Clearly And Do Not Write In Dark Shaded Area)
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First Name |
M.I. |
Last Name |
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HOME PHONE |
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APPLICANT |
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HOME ADDRESS |
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Apt. |
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IS THIS A SHELTER? YES __ NO__ |
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MAILING ADDRESS |
Street/P.O. Box |
Apt. |
City |
State |
Zip Code |
County |
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(If different from above) |
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NAMES (List your name first. Include aliases and maiden name) |
6 |
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First |
M.I. |
Last |
Date Of Birth |
Sex Social Security Number Race/Ethnic |
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Code |
SELF |
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SPOUSE
CHILD*
*If under 18 years of age. Attach extra sheet if necessary to list additional children.
B - Black, not of Hispanic origin |
W - White, not of Hispanic origin |
H – Hispanic |
U - Unknown |
Race/Ethnic affiliation codes: |
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A - Asian or Pacific Islander |
I - American Indian/Alaskan Native |
O – Other |
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Are you a U.S. Citizen?
If No, do you have satisfactory immigration status? Include Alien Number, Date of Status, and Date Entered Country, if applicable.
__Yes |
__No |
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Alien Number |
_____________________ |
__Yes |
__No |
_____________________ |
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Date of Status (DOS) |
Date Entered Country (DEC) _____________________
Is your spouse a U.S. Citizen? |
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__Yes |
__No |
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If No, does your spouse have satisfactory |
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Alien Number |
_____________________ |
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immigration status? Include Alien Number, |
__Yes |
__No |
Date of Status (DOS) |
_____________________ |
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Date of Status, and Date Entered Country, |
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if applicable. |
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Date Entered Country (DEC) |
_____________________ |
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APPLICANT’S MEDICARE INFORMATION |
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Medicare # ____________________________(From red and blue Medicare card) |
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Do you have Medicare Part A? |
__Yes |
__No |
Effective Date ___________________________ |
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Do you have Medicare Part B? |
__Yes |
__No |
Effective Date ___________________________ |
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SPOUSE’S MEDICARE INFORMATION, if applying |
Medicare # ___________________________(From red and blue Medicare card) |
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Does spouse have Medicare Part A? |
__Yes |
__No |
Effective Date __________________________ |
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Does spouse have Medicare Part B? |
__Yes __No |
Effective Date __________________________ |
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Would you like us to consider providing retroactive reimbursement of your Medicare premium? |
__Yes __No |
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Do you or your spouse pay any health |
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insurance premiums other than Medicare? |
__Yes |
__No |
Who? __________________________ Monthly Amount $______________ |
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Do you or your spouse pay child/spousal |
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support? |
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__Yes |
__No |
Who? __________________________ Monthly Amount $______________ |
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Do you or your spouse receive payments |
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from or are named beneficiary of a trust? |
__Yes |
__No |
Who? __________________________ Value $______________ |
List below all available income such as: salary, wages, pension, social security, severance pay, rental or business income, etc.
Names of Applicant, Spouse, or Child under 18 |
Who Provides the Money? |
What Amount? |
How Often? |
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(Attach an extra sheet if necessary) |
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(Name/source of Income) |
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(weekly, two weeks, monthly) |
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$ |
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$ |
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$ |
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Do you want to receive notices in: |
__ English Only |
__ Spanish and English |
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PAYMENT OF YOUR MEDICARE PREMIUM IS A MEDICAID BENEFIT
PENALTIES: I understand that my application may be investigated, and I agree to cooperate in such an investigation. Federal and State laws provide for penalties of fine, imprisonment or both if you do not tell the truth when you apply for Medicaid benefits or at any time when you are questioned about your eligibility, or cause someone else not to tell the truth regarding your application or your continuing eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your initial and continuing eligibility for Medicaid or if you conceal or fail to disclose facts that would effect the right of someone for whom you have applied to obtain or continue to receive Medicaid benefits; and such benefits must be used by the other person and not for yourself.
CHANGES: I agree to inform the agency promptly of any change in my needs, income, property, living arrangements or address to the best of my knowledge or belief.
SOCIAL SECURITY NUMBER (SSN): If you are applying for the Medicare Savings Program, you must
report your SSN, unless you are a pregnant woman. The laws requiring this are: 18NYCRR Sections 351.2,
CERTIFICATION OF CITIZENSHIP & IMMIGRATION STATUS: I certify, under the penalty of perjury, by signing my name on this application, that I, and/or any person for whom I am signing is a U.S. citizen or national of the United States or has satisfactory immigration status. I understand that information about me will be submitted to the United States Citizenship and Immigration Services (USCIS) for verification of my immigration status, if applicable. I further understand that the use or disclosure of information about me is restricted to persons and organizations directly connected with the verification of immigration status and the administration and enforcement of the provisions of the Medicaid program.
CERTIFICATION: In signing this application, I swear and affirm that the information I have given or will give to the Department of Social Services as a basis for Medicaid is correct. I also assign to the Department of Social Services any rights I have to pursue support from persons having legal responsibility for my support and to pursue other
CONSENT: I understand that by signing this application/certification form I agree to any investigation made by the Department of Social Services to verify or confirm the information I have given or any other investigation made by them in connection with my request for Medicaid. If additional information is requested, I will provide it.
Applicant/Representative
Signature X ______________________________________________________ Date _____________
Spouse Signature X _______________________________________________ Date _____________
Representative Address, Phone Number and Relationship ___________________________________________________
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If after reading and completing this form, you decide that you DO NOT want to apply for the Medicare Savings Program please sign on the following line.
I consent to withdraw my application ___________________________________ Date ____________
SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION: |
DATE: |
EMPLOYED BY: |
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x |
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Eligibility Determined By Worker: |
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Eligibility Approved By: |
________________________ |
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(DATE) |
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(DATE) |
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CENTRAL/OFFICE |
APPLICATION DATE |
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UNIT ID |
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WORKER ID |
CASE TYPE |
CASE NO |
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REUSE IND. |
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CASE NAME |
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DISTRICT |
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REGISTRY NO. |
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VER. |
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REASON CODE |
PROXY: |
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Effective Date ___________ MA Disp. |
Denial |
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Withdrawal |
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Yes |
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No |
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