Please rate Doh 4328 Msp Application 11-23
Be sure to answer all the questions.
Married: if you are married and living with your spouse, you must complete both the Self and Spouse questions (even if the spouse is not applying for the MSP).
Signatures: if both spouses are applying, both must sign the MSP application.
Retroactive reimbursement: if you are requesting retroactive reimbursement of your Medicare premiums, you must send proof of income for the previous three-months.
Applying spouse: if there is an applying spouse, the spouse must also provide documentation.
Immigration status: if you are not a U.S. citizen, you must provide documents indicating your current immigration status.
| Question | Answer |
|---|---|
| Form Name | DOH-4328 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 131 |
| Avg. time to fill out | 22 min |
| Edition | Rev 11/23 |
| Issuing agency | New York State Department of Health |
| Where to send | Your local Department of Social Services (LDSS) or Human Resource Administration (HRA), with the required documentation |
| Other names | DOH-4328, DOH 4328, DOH4328, MSP application, Medicare Savings Program application, MSP form |
| Official source | DOH-4328 (Rev 11/23), New York State Department of Health |
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Please rate Doh 4328 Msp Application 11-23
