Form Doh 4282 – Fill Out and Use This PDF

Pleaseprintclearly. Pleaseaskforhelpifthereisanythingyoudonotunderstand.

SECTION A	CONTACT INFORMATION
Telluswhoyouareandhowtocontactyou.
FirstName,MiddleInitial,LastName					PrimaryLanguageSpoken
HomeAddressStreet		Apt. No.	City		State	ZipCode	County
Ifyoudonotwanttoreceivemailorabenefitcardatyourhomeaddressforconfidentialitypurposes,pleasegiveadifferentaddressbelow.
MailingAddressStreet(IfDifferent)		Apt. No.	City		State	ZipCode	County
PhoneNumber(s)WhereYouCanBeReached				IsAnyoneintheHouseholdaVeteran?If YES, listname:

SECTION B

HOUSEHOLD INFORMATION

ListthenamesofpeoplelivingwithyouwhoareapplyingforFPBP. Youmustlistyourspousethatliveswithyouevenifyourspouseisnotapplying.

Ifyoulivewithothers,suchasyourchildren,youmaylistthemeveniftheyarenotapplying.

IsthisPerson

FORFPBPAPPLICANTSONLY

FirstName,MiddleInitial,LastName

DateofBirth

ApplyingforFamily

Race/EthnicGroup

(UseAnotherPageifYouNeedtoListMorePeople)

(MM/DD/YY)

Sex

RelationshiptoPersononLine1

PlanningBenefits?

SocialSecurityNumber

(SeeCodes)

1

Male

Self

Yes

Female

No

2

Male

Yes

Female

No

3

Male

Yes

Female

No

4

Male

Yes

Female

No

Race/Ethnic Group Codes (Optional):

B: BlackorAfricanAmerican

A: Asian W: White

H: HispanicorLatino I: AmericanIndianorAlaskanNative P: NativeHawaiianorOtherPacificIslander U: Unknown

SECTION C

HOUSEHOLD INCOME

ListthetypesofmoneyandtheamountreceivedbyanyonelistedinSectionB. Besuretoincludeearningsfromwork,childsupportpayments,unemployment

benefits,interest,SocialSecuritybenefits,pensions,disabilitypayments,moneyfromrelativesorfriendsoranyotherpayments.

TypeofCurrentIncome

HowMuchDoesthePersonReceive?

HowOftenistheIncomeReceived?

NameofPersonWorkingorReceivingMoney

(Example:Wages,UIB,SSABenefits)

(BeforeTaxes)

(Weekly,EveryTwoWeeks,Monthly,Other)

Ifyouhavenoincome,pleaseexplainhowyouaremeetingyourneeds(forexample,livingwithfriendsorrelatives),andifyouareastudent:

Doyouhavetopayforchildcare(orforcareofadisabledadult)inordertoworkorgotoschool?

Yes

No If YES:

Name(s)

HowMuch?

HowOften?(Weekly,Monthly)

SECTION D

CITIZENSHIP

Thisinformationisneededforallperson(s)applyingforfamilyplanningbenefits.

AllpersonsapplyingforFamilyPlanningBenefitsmustsubmitoriginaldocumentationoftheircitizenshipandidentity. Ifyouhavealreadydoneso,youdonot needtoshowusagainatrenewal. YourproviderorworkerwilladviseyouastowhattheacceptableformsofdocumentationareaccordingtoFederalguidelines.

IseveryonewhoisapplyingaU.S. citizen,nationalorNativeAmerican?	Yes	No
If NO,pleasegivethefollowinginformationforanyone applying forfamilyplanningbenefitswhoarenotU.S. citizens. Youranswerstothesequestionswill
bekeptcompletelyconfidential.
		DoesThisPersonBelongtoAnyoftheCategories			IfAorB,OnWhatDateDidthePerson
FirstName,MiddleInitial,LastName		ListedBelow?ChecktheAppropriateBox.			EntertheUnitedStates?(MM/DD/YY)
		A	B	None
		A	B	None

SECTION E HEALTH INSURANCE

Youmaystillbeeligibleevenifyouhaveotherhealthinsurance,especiallyifitdoesnotcoverfamilyplanningservices,orifyouhaveagoodcausereasonthat

yourhealthinsuranceshouldnotbebilled.

Doesanyoneinyourhouseholdhave Medicaid, Medicare, FamilyHealthPlusor ChildHealthPlus?If YES, givethenameofanyonewithcoverage:

Name(s)

DoesanyonehaveotherhealthinsurancethatcoversapersonapplyingfortheFamilyPlanningBenefitProgram?		Yes	No	IDon’tKnow If YES:
Name(s)ofPerson(s)Covered
NameofSubscriber/PolicyHolder				Group/PolicyNumber
InsuranceCompanyName				MonthlyPremiumCost
Ifyouarenotthepolicyholder,doyouhaveareasonthehealthinsurancecompanyshouldnotbebilled?	Yes	No	Pleaseexplain:

DOH-4282 (9/09) Page 1 of 2

TERMS, RIGHTS AND RESPONSIBILITIES

By completing and signing this application, I am applying for the Family PlanningBenefit Program (FPBP). I agree to the release of personal and financial informationfrom this application and any other information needed to determine eligibility. I understand thatI may be asked for more information. I agree to immediately report any changes to the information on this application.

I understand that I must provide the information needed to prove my eligibility. If I have been unable to get the information, I will tell the social services district. The social services district may be able to help in getting the information.

I understand the FPBP may check the information given by me for this application without my confidentiality being compromised. The state, social services district and provider who assist in completing this application will keep this information confidential according to 42 U.S.C. 1396a(a)(7) and 42 CFR 431.300-431.307, and any federal and state laws and regulations.

I understand that my eligibility for this program will not be affected by my race, color,disability, sex, or national origin. I also understand that depending on the requirements of this program, my age or citizenship status may be a factor in whether or not I am eligible.

I understand that anyone who knowingly lies or hides the truth in order to receive services under this program is committing a crime and subject to federal and state penalties and may have to repay the amount of benefits received and may also be given civil penalties.

IunderstandthatImustprovideoriginaldocumentationofmycitizenshipandidentitytotheSocialServicesDistrictortotheFamilyPlanningProvideronbehalfofthe localdistricttoreceiveFamilyPlanningBenefits. Ialsounderstandthatthesocialservicesdistrictcanassistmeindeterminingmystatusandobtaininganynecessary documentsifIrequesthelp. OnceIhaveprovidedmyoriginaldocumentsfortheworkertodocumentmycitizenshipandidentity,Iwillnothavetoprovidethemagain. IfIamfillingoutthisformasamail-inrenewal,andhavenotyetprovidedtheseoriginaldocuments,Ishouldnotmailthem,butshouldgotothelocaldistrictoffice toshowthemtoaworker,sotheymayrecordtheoriginalshavebeenseen. SocialServiceswillnotkeepmyoriginaldocuments.

Immigration: United States Citizenship and Immigration Services (USCIS) has said that enrollment inMedicaid CANNOT affect a person’s ability to get an identification card, become a citizen, sponsor a family member or travel in and out of the country (except if Medicaid pays for long term care in a place like a nursing home or a psychiatrichospital).

TheStatewillnotreportanyinformationonthisapplicationtotheUSCIS.

ASSIGNMENT OF RIGHTS FOR MEDICAL SUPPORT AND THIRD PARTY PAYMENT

I understand that FPBP does not pay medical expenses that insurance or another person is supposed to pay, unless there is good cause not to use other insurance. All personsapplying for FPBP are required to give to the Medicaid agency any rights they may haveto medical support or other insurance payments for family planning services, unlessthey request and receive a good cause exemption. When I sign this application for myself, or for another person for whom I can legally give away rights, I am giving to the Medicaid agency all of my rights to receive medical support and third party payments for family planning services for the entire time I am on Medicaid.

REIMBURSEMENT OF MEDICAL EXPENSES

After the date of my application, reimbursement of covered family planning services andsupplies will only be available if obtained from Medicaid-enrolled providers.

SOCIAL SECURITY NUMBER (SSN)

I understand that I must give my SSN in order to receive FPBP. This is required bysection 1137(a) of the Social Security Act and the Medicaid regulations (42 CFR 435.910 and42 U.S.C. 1320b-7(a) ). The FPBP will use the SSN to verify my income, eligibility, and theamount of medical assistance payments made on my behalf. The information may be matched with the records in other agencies, such as the Social Security Administration and/or the Internal Revenue Service.

CONFIDENTIALITY STATEMENT

All of the information you provide to us will remain confidential. The only people who will see this information are the state or local agencies and the person assisting you in completing the application that need to know this information in order to determine if you are eligible. The person helping you with this application cannot discuss the information with anyone, except a supervisor or the state or local agencies that need this information.

RELEASE OF MEDICAL INFORMATION

I consent to the release of any medical information about me and any members of my family for whom I can give consent by: my Primary Care Provider, any other health care provider or the New York State Department of Health (SDOH) and any health care provider involved in caring for me or my family, as reasonably necessary for my providers to carry out treatment, payment, or health care operations, to SDOH and other authorized federal, state, and local agencies for purposes of administration of the Medicaid program. I also agree that the information released may include HIV, mental health or alcohol and substanceabuse information about me and members of my family to the extent permitted by law.

IcertifythatIhavereadandunderstandtheTerms,RightsandResponsibilitiesabove. Icertifyunderpenaltyofperjurythateverythingonthisapplicationisthetruth asbestIknow.

Date ____________ Applicant’s Signature ___________________________________ Spouse’s Signature (If Applying) ________________________________

DECLINATIONOFMEDICAIDANDFAMILYHEALTHPLUSELIGIBILITYDETERMINATIONS

I, ________________________________________________,havebeeninformedoftheenhancedbenefitsandadditionalservicesandcoverageavailableunder

MedicaidandFamilyHealthPlus. IchoosenottoapplyforMedicaidandFamilyHealthPlusatthistime,andhaverequestedaneligibilitydeterminationfortheFamily

PlanningBenefitProgramonly. IunderstandthatImayapplyfortheseotherprogramsatanytimeinthefutureifIwish.

Date ____________ Applicant’s Signature ____________________________________ Provider/Medicaid Staff Signature _______________________________

IFAFTERREADINGANDCOMPLETINGTHISFORM,YOUDECIDETHATYOUDONOTWANTTOAPPLYFORTHEFAMILYPLANNINGBENEFITPROGRAM,pleaseSIGNyournamebelow:

Iconsenttowithdrawmyapplication,andunderstandthatImayreapplyatanytime:

Date ____________ Applicant’s Signature _____________________________________________________________________________________________

FOR OFFICE USE ONLY

ToBeCompletedBythePersonAssistingWiththeApplication:

Signature of Person Who Obtains Eligibility Information_________________________________________ Employed By ___________________________________

Have Original Documents Been Seen for Citizenship/Identity?

Yes

No (Applied For)

ToBeCompletedBytheLocalSocialServicesDistrict:

Eligibility Determined By _______________________________________________________________________________________ Date_________________

Eligibility Approved By ________________________________________________________________________________________ Date_________________

Center Office: ____________	Application Date: ____________	Unit ID: ________________	Worker ID: ___________	Version:_____________
Case Name: _____________	District: ___________________	Case Type: ______________	Case No: ____________
Effective Date: ___________	MA Disposition Reason Code: ___________________________		Proxy: ______________	Reg. No._____________

DOH-4282 (9/09) Page 2 of 2