Doh 4328 Pdf Details

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QuestionAnswer
Form NameDoh 4328 Msp Application
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespdf medicare savings program, doh 4328 form, ny medicare savings, medicare savings application form

Form Preview Example

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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