Doh 4328 Msp Application ≡ Fill Out Printable PDF Forms Online

Question	Answer
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

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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)

	First Name	M.I.	Last Name			HOME PHONE
APPLICANT

HOME ADDRESS	Street	Apt.	City	State	Zip Code		County
IS THIS A SHELTER? YES __ NO__

MAILING ADDRESS	Street/P.O. Box	Apt.	City	State	Zip Code		County
(If different from above)

	NAMES (List your name first. Include aliases and maiden name)			6


First	M.I.	Last	Date Of Birth	Sex Social Security Number Race/Ethnic
				Code
SELF

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:
A - Asian or Pacific Islander	I - American Indian/Alaskan Native	O – Other

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
	Alien Number	_____________________
__Yes	__No	_____________________
	Date of Status (DOS)	_____________________

Date Entered Country (DEC) _____________________

Is your spouse a U.S. Citizen?		__Yes	__No
If No, does your spouse have satisfactory				Alien Number	_____________________
immigration status? Include Alien Number,		__Yes	__No	Date of Status (DOS)	_____________________
Date of Status, and Date Entered Country,

if applicable.				Date Entered Country (DEC)	_____________________

APPLICANT’S MEDICARE INFORMATION			Medicare # ____________________________(From red and blue Medicare card)
Do you have Medicare Part A?	__Yes	__No	Effective Date ___________________________
Do you have Medicare Part B?	__Yes	__No	Effective Date ___________________________

SPOUSE’S MEDICARE INFORMATION, if applying			Medicare # ___________________________(From red and blue Medicare card)
Does spouse have Medicare Part A?	__Yes	__No	Effective Date __________________________
Does spouse have Medicare Part B?	__Yes __No		Effective Date __________________________

Would you like us to consider providing retroactive reimbursement of your Medicare premium?					__Yes __No

Do you or your spouse pay any health
insurance premiums other than Medicare?		__Yes	__No	Who? __________________________ Monthly Amount $______________

Do you or your spouse pay child/spousal
support?		__Yes	__No	Who? __________________________ Monthly Amount $______________

Do you or your spouse receive payments
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?
(Attach an extra sheet if necessary)		(Name/source of Income)			(weekly, two weeks, monthly)
				$


				$

				$

Do you want to receive notices in:	__ English Only		__ Spanish and English

DOH-4328 (6/08)

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, 360-1.2, and 360-3.2(j)(3); 42USC 1320b-7. SSNs are used in many ways, both within the local social services districts and also between local social services districts and federal, state, and local agencies, both in New York and in other jurisdictions. Some uses of SSNs are: to check identity, to identify and verify earned and unearned income, to see if absent parents can get health insurance for applicants, to see if applicants can get child support and to see if applicants can get money or other help.

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.

NON-DISCRIMINATION NOTICE: This application will be considered without regard to race, color, sex, disability, religious creed, national origin, or political belief.

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 third-party resources. I understand that Medicaid paid on my behalf may be recovered from persons who had legal responsibility for my support at the time medical services were obtained.

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 ___________________________________________________

_____________________________________________________________________________________________________

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:
x
Eligibility Determined By Worker:		________________________				Eligibility Approved By:		________________________
				(DATE)						(DATE)
CENTRAL/OFFICE	APPLICATION DATE		UNIT ID		WORKER ID	CASE TYPE	CASE NO				REUSE IND.

CASE NAME			DISTRICT			REGISTRY NO.			VER.

						REASON CODE		PROXY:
Effective Date ___________ MA Disp.			Denial		Withdrawal			Yes			No

DOH-4328 (6/08) Reverse

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