If you have unpaid medical bills, related to family planning, from the last 3 months, you must provide proof of your income and residency for the month(s) when unpaid services were received.
Household: you may list your spouse and your children under 21, even though they are not applying.
Income: list ALL of the type(s) and amount(s) of money you receive.
Health insurance: you may still be eligible even if you have other health insurance, especially if it does not cover family planning services.
SSN: the applicant understands they must give their SSN in order to receive FPBP.
| Question | Answer |
|---|---|
| Form Name | DOH-4282 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 65 |
| Avg. time to fill out | 11 min |
| Edition | 8/14 |
| Issuing agency | New York State Department of Health Office of Health Insurance Programs |
| Who signs | The applicant |
| Other names | DOH-4282, DOH 4282, DOH4282, NY DOH-4282, New York DOH-4282, Family Planning Benefit Program Application, FPBP application |
| Official source | DOH-4282 (Rev 8/14), New York State Department of Health |
Form Doh 4282 isn’t the one you’re looking for?