Map 751K Form PDF Details

The Map 751K form serves a critical role for individuals seeking to amend their personal details on file with the health services department, specifically within the context of consumer requests for changes in information. Engaging with this form is a process initiated for a variety of reasons, including modifications in name, date of birth, gender information, social security number, immigration status, and the reporting of a death. Additionally, it outlines the necessity for documentation when requesting certain changes like Community Based Long-Term Care coverage and coverage for nursing home services, which demand specific financial documentation. The form goes further to differentiate between changes that do require documentation and those that do not, such as address changes and updates to contact information. Crucially, it highlights the importance of providing identification and appropriate documentation to validate the request, ensuring that changes are made accurately and to the benefit of the involved parties. By guiding consumers through the necessary steps to update their information, whether for correcting errors or reflecting significant life changes, the Map 751K form embodies a vital tool in maintaining up-to-date and accurate records within health services databases.

QuestionAnswer
Form NameMap 751K Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform map751k, map751k form, map 751k form printable, map 751k 2020

Form Preview Example

 

CONSUMER REQUEST TO CHANGE INFORMATION ON FILE

 

 

 

 

 

 

 

 

MAP-751k (E) 11/13/2012

Case Name: __________________________________________

Case Number: ____________________________________

 

CHANGE REQUESTS REQUIRING DOCUMENTATION

 

 

 

 

 

Name:

from

to

 

 

 

Date of Birth:

for

from

to

 

 

Gender Information:

for

from

to

 

 

Change Social Security Number:

for

from

to

 

 

Immigration Status:

for

from

to

 

Notification of Death:

for

date of death

 

 

 

Coverage Type (RVI) Upgrade:

for

from

to

 

Community Based Long-Term Care coverage, which includes coverage for home care and waiver services, requires resource documentation for the current month only. Coverage for nursing home services requires resource documentation for the past 60 months and an immediate need for the services.

NOTE: You must provide identification to prove that you are either an adult household member on the case or have authorization to request changes on their behalf, along with documents to support the change you are requesting.

 

Signature of Consumer: _____________________________________________________

Date: ________________________

 

 

 

 

 

 

 

 

 

 

 

 

CHANGE REQUESTS NOT REQUIRING DOCUMENTATION

 

 

 

 

Change of Residency Address:

 

from

to

 

 

 

Within New York City

 

 

 

 

 

 

Within New York State

 

 

 

 

 

 

Outside of New York State

 

 

 

 

 

 

Change of Mailing Address:

 

from

to

 

 

 

 

 

 

 

 

 

 

Add/Change of Secondary

 

from

to

 

 

 

Mailing Address:

 

 

 

 

 

 

Add Social Security Number (SSN):

 

for

her/his SSN is

 

 

 

 

 

 

 

 

Add/Change of Phone Number:

 

from

to

 

 

 

 

 

 

 

 

 

 

Remove the Following Person

 

 

 

 

 

 

From Medicaid Case:

 

 

 

 

 

 

Combine Medicaid Case

 

current number

with

 

 

 

 

 

 

 

 

 

 

Close Medicaid Case

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Consumer: _____________________________________________________

Date: ________________________

ASK MEDICAL ASSISTANCE PROGRAM STAFF TO ADVISE YOU IF DOCUMENTATION IS REQUIRED:

Other: (Specify) ___________________________________________________________________________________________

_____________________________________________________________________________________________________________

Signature of Consumer: _____________________________________________________ Date: ________________________

TO BE COMPLETED BY MEDICAL ASSISTANCE PROGRAM STAFF [Check box(es) that apply]

The documents checked below were provided by the consumer and the requested change(s) were made to her/his case file.

Birth/Death Certificate

SSA Award Letter

Driver’s License

Bank/Financial Statements

None Required

 

 

 

 

 

 

Passport

SS Card

Court Document

Other (specify)

 

 

 

 

 

 

 

Signature of MAP Staff:

 

 

 

Date:

 

 

 

 

 

 

 

How to Edit Map 751K Form Online for Free

Making use of the online editor for PDFs by FormsPal, you'll be able to fill in or modify map751k right here. To retain our editor on the cutting edge of practicality, we work to put into operation user-driven capabilities and improvements regularly. We are at all times looking for feedback - join us in remolding how we work with PDF docs. For anyone who is seeking to get going, here is what it takes:

Step 1: Click the "Get Form" button in the top part of this page to open our editor.

Step 2: When you launch the PDF editor, you'll notice the document ready to be filled out. In addition to filling out various blanks, you can also do some other actions with the form, that is putting on your own words, modifying the initial textual content, inserting images, signing the PDF, and much more.

When it comes to fields of this precise form, here is what you want to do:

1. Fill out your map751k with a selection of major blank fields. Consider all of the important information and make sure there's nothing neglected!

751k form writing process described (step 1)

2. Once your current task is complete, take the next step – fill out all of these fields - CHANGE REQUESTS NOT REQUIRING, Change of Residency Address, from, Within New York City Within New, Change of Mailing Address, AddChange of Secondary, Mailing Address, from, from, Add Social Security Number SSN, for, AddChange of Phone Number, from, Remove the Following Person, and From Medicaid Case with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling out section 2 in 751k form

People frequently make some mistakes when completing AddChange of Secondary in this area. Be sure to reread whatever you enter here.

3. The following part focuses on The documents checked below were, BirthDeath Certificate, SSA Award Letter, Drivers License, BankFinancial Statements, None Required, Passport, SS Card, Court Document, Other specify, Signature of MAP Staff, and Date - type in these empty form fields.

BirthDeath Certificate, BankFinancial Statements, and None Required inside 751k form

Step 3: Immediately after proofreading your form fields you've filled in, click "Done" and you are all set! Create a free trial subscription at FormsPal and acquire instant access to map751k - downloadable, emailable, and editable in your personal cabinet. Here at FormsPal.com, we do our utmost to make sure that your details are stored private.

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