Fillable Printable Health Insurance Application
Fillable Printable Health Insurance Application
Health Insurance Application
for Children,
Adults and
Families
Health
Insurance
application
DOH-4220-I 5/13 (page 2 of 4) NYS DOH
CONFIDENTIALITY STATEMENT All of the information you provide on this application will remain confidential. The only people who will
see this information are the Facilitated Enrollers and the State or local agencies and health plans who need to know this information in order to
determine if you (the applicant) and your household members are eligible. The person helping you with this application cannot discuss the
information with anyone, except a supervisor or the State or local agencies or health plans which need this information.
SECTION B
Household Information
SECTION A
Applicant’s Information
We need to be able to contact the people applying for health
insurance. The home address is where the people applying for
health insurance live. The mailing address, if different, is where you
want us to send health insurance cards and notices about your case.
You can also tell us if you want someone else to get information
about your case and/or to be able to discuss your case.
INSTRUCTIONS
Please Read the entire application booklet before you begin to fill out the application. If you are applying ONLY for children or if you are a
pregnant woman applying alone, you must complete only sections a through G and sections I and J. Other applicants must complete all sections.
If you are 65 years old or older, certified blind, certified disabled, or institutionalized and applying for coverage of nursing home care, you must also
complete supplement a. The supplement includes questions about your resources, such as money in the bank or property you own.
Whenever you see the words on the application refer to the “Documentation Needed When You Apply for Health Insurance”
section for a listing of acceptable supporting documents.
HOW TO GeT HelP When applying for public health insurance, you dO NOT need to visit your local department of social services or a
Facilitated Enroller for an interview, but you MaY come in or contact a Facilitated Enroller for help filling out this application. You can get a list of
Facilitated enrollers where you got this application, or by calling 1-800-698-4543. all HelP Is FRee.
(1-877-898-5849 TTY line for the hearing impaired)
PURPOse OF THIs aPPlICaTION Complete this application if you want health insurance to cover medical expenses. This application
can be used to apply for Medicaid, Family Health Plus, Child Health Plus, the Family Planning Benefit Program, or for assistance paying your health
insurance premiums. You can apply for yourself and/or immediate family members living with you.
IF YOU NEED HELP COMPLETING THIS APPLICATION DUE TO A DISABILITY, CALL YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. THEY WILL MAKE
EVERY EFFORT TO PROVIDE REASONABLE ACCOMMODATIONS TO ADDRESS YOUR NEEDS.
Please include information for everyone who lives with you
even if they are not applying for health insurance. It is important
that you list everyone who lives with you so that we can make
a correct eligibility decision. Include maiden name (legal name
before marriage), if this applies to the person. Also include City,
State and Country of birth. If a person was born outside of the
United States, just write the country of birth. We also need,
for each person applying, his/her mother’s full maiden name
(first and last name). This information may be used to obtain
proof of the applicant’s birth date under certain circumstances.
Is this person pregnant? If so, when is her baby due to be
born? This information helps us determine the size of your
family. A pregnant woman counts as two people.
Relationship to the person on Line 1. Explain how
each person is related to the person listed on Line 1
(for example, spouse, child, step-child, brother, sister,
niece, nephew, etc.)
Public Health Coverage. If you or anyone who lives with you
is already enrolled or was previously enrolled in Medicaid,
Family Health Plus, Child Health Plus, the Family Planning
Benefit Program, or any other form of public assistance such as
Food Stamps, we need to know. Also, tell us the identification
number on the New York State Benefit Identification Card or
plan identification card for Child Health Plus.
Social Security Number. A Social Security Number should
be provided for all persons applying, if the person has one.
If the person does not have a Social Security Number, leave
this box blank.
Citizenship and Immigration Status. This information is
needed only for those people applying for health insurance.
Pregnant women do not have to complete this question.
To be eligible for health insurance, other persons age 19 and
over must be U.S. citizens or be in an eligible immigration
category. We need to see either original documentation of
U.S. citizenship and identity, or certified copies of these
documents. Please contact your local department of social
services or call 1-800-698-4543 to find out where you can
bring these documents. Please note that if you are on
Medicare, or receiving Social Security Disability but are not
yet eligible for Medicare, it is not necessary to document
citizenship or identity.
Effective July 1, 2010, citizen children who provide their
Social Security Number are not required to provide identity
or citizenship documentation if eligible for Child Health Plus.
Children who are New York State residents and do not have
other health insurance are eligible, regardless of their
immigration status.
SEND PROOF
Write in your monthly cost of housing. This includes your rent,
monthly mortgage payment or other housing payment. If you have
a mortgage payment, include property taxes in the amount you tell
us. If you share your housing expenses or your rent is subsidized,
please only tell us how much YOU pay toward your rent or mortgage.
If you pay for your water, tell us how much you pay and how often.
If you have paid or unpaid medical bills from the past three months,
Medicaid may be able to pay for these costs. Let us know who these
bills are for and in which months. Include copies of the medical bills
with this application. Note: This three-month period begins when the
local department of social services receives your application or when
you meet with a Facilitated Enroller. You will need to tell us what
your income was for any past months in which you have medical
bills so that we can see if you are eligible during that time. We also
ask about where you lived in the past three months, because this
may affect our ability to pay for past bills. We ask about any pending
lawsuits or health issues caused by someone else so we know if
someone else should pay for any portion of your medical care costs.
These questions help us determine which program is best for
each applicant, and what services may be needed. A person with
a disability, serious illness or high medical bills may be able to
get more health services. You may have a disability if your daily
activities are limited because of an illness or condition that has
lasted or is expected to last for at least 12 months. If you are blind,
disabled, chronically ill or need nursing home care, you will need to
complete Supplement A. If neither you nor anyone applying is blind,
disabled, chronically ill or in a nursing home, go to Section G.
DOH-4220-I 5/13 (page 3 of 4) NYS DOH
Health Insurance
Housing Expenses
Additional Health Questions
Blind, Disabled, Chronically Ill
or Nursing Home Care
Household Income
(Money Received)
In this section, list all types of income (money received) and
the amounts received by the people you listed in Section B.
Please tell us how much you make before taxes are taken out.
If there is no money coming into your home, explain how you
are paying for your living expenses, such as food and housing.
We need to know if you have changed jobs or if you are
a student.
We also need to know if you pay another person or place, such
as a day care center, to take care of your children or disabled
spouse or parent while you are working or going to school. If
you do, we need to know how much you pay. We may be able
to deduct some of the amount that you pay for these costs
from the amount we count as your income.
PUBLIC CHARGE INFORMATION
The United States Citizenship and Immigration Services (USCIS)
has stated that enrollment in Medicaid, Family Health Plus, Child
Health Plus or the Family Planning Benefit Program CANNOT affect
a person’s ability to get a green card, become a citizen, sponsor a
family member, or travel in and out of the country. This is not true if
Medicaid pays for long-term care in a place such as a nursing home
or psychiatric hospital.
The state will not report any information on this application to
the UsCIs.
Race/Ethnic Group. This information is optional and it will
help us make sure that all people have access to the programs.
If you fill out this information, use the code shown on the
application that best describes each person’s race or ethnic
background. You may pick more than one.
SECTION C
SECTION D
SECTION E
SECTION G
SECTION F
It is important to tell us whether anyone applying is covered
or could be covered by someone else’s
health insurance. This information may
affect their eligibility for coverage;
for some applicants, we can deduct
the amount that you pay for health
insurance from the amount we
count as your income; or we may
be able to pay the cost of your
health insurance premium if
we determine it is cost effective.
Some children who had employer-
based health insurance within the
past six months may be subject
to a waiting period before they can
enroll in Child Health Plus. This will
depend on your household income
and the reason your children lost
employer-based coverage.
NOTE: State Health Benefits Plans provide
health insurance coverage through the
New York State Health Insurance Program
(NYSHIP). Coverage is offered to employees/
retirees of NYS government, the State Legislature and the Unified Court
System. Some local government agencies and school districts also elect
to participate in NYSHIP. If you are not sure, check with your employer.
If your child has access to State Health Insurance Benefits through
NYSHIP, he/she will be ineligible for Child Health Plus coverage.
We may be able to help pay for health insurance premiums if you
have or can get insurance through your job. We will need to gather
more information about the insurance and will mail an insurance
questionnaire to you.
DOH-4220-I 5/13 (page 4 of 4) NYS DOH
State of New York
Department of Health
SECTION I
Health Plan Selection
What is a Health Plan? Applying for programs through Access NY
Health Care may mean you get your health care coverage through a
Managed Care plan. When you join a plan, you choose one doctor
(Primary Care Provider or PCP) from that plan to take care of your
regular needs. If you want to keep the doctor you have, you need to
pick the plan that works with your doctor. Managed Care health
plans focus on preventive care so small problems do not become big
ones. If you need a specialist, your PCP will refer you to one.
Who Must Choose a Health Plan? People who are eligible for Family
Health Plus and Child Health Plus MUsT choose a health plan to get
medical care. MOsT people who are eligible for Medicaid MUsT
choose a health plan to get most of their Medicaid benefits. Keep
reading to find out how to get more information on this.
SECTION J
Signature
Please read the paragraph in this section carefully and read the
Terms, Rights and Responsibilities section. You must then sign and
date the application.
NOTe: If you or a family member are found eligible for Medicaid,
and are in a county that does not require people on Medicaid to join
a health plan, you will still be enrolled in the health plan you choose
if it provides Medicaid, unless you check the box on the application
that says you don’t want to be enrolled, or tell us you do not want
to be enrolled by calling or writing to your local department of
social services.
For Child Health Plus:
For information about Child Health Plus plans, call 1-800-698-4543.
Child Health Plus Premium
There are no premiums for Medicaid, or Family Health Plus. There
may be a monthly premium for Child Health Plus. Use the enclosed
chart to determine if you need to pay a premium based on your
monthly income. You must include the first month’s premium with
the completed application or your child will not be enrolled.
Parent or Spouse Not Living in
the Household or Deceased
If any applicants have an absent spouse or parent, you must
complete this section so we can see if medical support is
available to you or your child.
Pregnant women do not have to answer these questions until
60 days after the birth of their child. All other people who are
applying and are age 21 or over must be willing to provide
information about a parent of an applying minor or a spouse
living outside the home to be eligible for health insurance,
unless there is good cause. An example of “good cause” is fear
of physical or emotional harm to you or a family member.
Question 2 refers to the PaReNT of any applying child under
age 21. Question 3 refers to the sPOUse of anyone applying.
If the parents are not willing to provide this information, the
applying child may still be eligible for Medicaid or Child
Health Plus.
SECTION H
How do I Know What Health Plan to Choose and If I Can enroll?
For Medicaid and Family Health Plus, if you want to find out more
about how managed care plans work, if you have to join, and how to
choose a plan, call Medicaid CHOICe at 1-800-505-5678, or call or
visit your local department of social services. Ask for a Managed
Care Education Packet. Information about health plans is also on
the NYSDOH website at www.nyhealth.gov. You can also
enroll by phone, by calling 1-800-505-5678.
DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE
NYS DOH
Effective 7/1/10, citizen children who provide a social security number are not required to provide identity or citizenship documentation if eligible for Child Health Plus.
You can provide ONE of the following documents to prove both U.S. Citizenship, Identity and your Date of Birth:
☐ U.S. passport book/card OR
☐ Certificate of Naturalization (DHS Forms N-550 or N-570) OR
☐ Certificate of U.S Citizenship (DHS Forms N-560 or N-561) OR
☐ NYS Enhanced Driver’s License (EDL).
When one of the above documents is not available, ONE document from EACH of the lists below may be used to prove your citizenship and/or identity.
This list is not all-inclusive. If you do not have one of these documents, please refer to the “How to Get Help” section of the instructions.
* Your enrollment cannot be completed until all NeCessaRY items are received. If you need help getting any of these items, let us know.
YOU dO NOT Need TO sHOW Us all OF THese dOCUMeNTs. We only need documents that apply to you or others who are applying. We will need to see original or certified copies
of documents for identity and U.s. citizenship. Please contact your local department of social services or call 1-800-698-4543 to find out where you can bring identity and U.s.
citizenship documents. Many local departments of social services and Child Health Plus health plans do not accept original documents by mail, so please check with them if you wish
to mail these documents. Copies of other documents can be mailed with your application.
U.s. Citizenship
☐ U.S. Birth Certificate*
☐ Certification of Birth issued by Department of State
(Forms FS-545 or DS-1350)*
☐ Report of Birth Abroad (FS-240)
☐ U.S. National ID card (Form I-197 or I-179)
☐ Native American Tribal Document*
☐ Religious/School Records*
☐ Military record of service showing U.S. place of birth
☐ Final adoption decree
☐ Evidence of qualifying for U.S. citizenship under the
Child Citizenship Act of 2000
Identity
☐ State Driver’s license or ID card with photo*
☐ ID card issued by a federal, state, or local government agency
☐ U.S. Military card or draft record or U.S Coast Guard
Merchant Mariner Card
☐ School ID card with a photo (may also show date of birth)
☐ Certificate of Degree of Indian blood or other Native American/Alaska Native
tribal document with photo
☐ Verified School, Nursery or Daycare records (for children under 16)
(may also show date of birth)
☐ Clinic, Doctor or Hospital records (for children under 16)*
DOH-4220B 5/13 (page 1 of 3)
applicant Name application date
*Please return all necessary items by: or application may be denied.
documents with * next to it also show date of birth
☐ Marriage certificate
☐ NYS Benefit Identification Card
You need to provide proof of Identity, U.s. Citizenship and/or Immigration status and date of Birth.
If you do not use one of the documents that show date of birth, you must also submit one of the following:
DOH-4220B 5/13 (page 2 of 3)
NYS DOH
☐ Driver’s license (if issued in the past 6 months)
☐ Government ID card with address
☐ Postmarked envelope or post card (cannot use if sent to a P.O. Box)
social security
☐ Award letter/certificate
☐ Annual benefit statement
☐ Correspondence from Social Security Administration
Workers’ Compensation
☐ Award letter
☐ Check stub
Child support/alimony
☐ Letter from person providing support
☐ Letter from court
☐ Child support/alimony check stub
☐ Copy of NY Epicard with printout
☐ Copy of child support account information from
www.newyorkchildsupport.com
☐ Copy of bank statement showing direct deposit
Veterans’ Benefits
☐ Award letter
☐ Benefit check stub
☐ Correspondence from Veterans Affairs
Military Pay
☐ Award letter
☐ Check stub
Income from Rent or Room/Board
☐ Letter from roomer, boarder, tenant
☐ Check stub
Interest/dividends/Royalties
☐ Recent statement from bank, credit union or
financial institution
☐ Letter from broker
☐ Letter from agent
☐ 1099 or tax return (if no other documentation
is available)
Wages and salary
☐ Paycheck stubs
☐ Letter from employer on company letterhead, signed and dated
☐ Current signed and dated income tax return and all Schedules**
☐ Business/payroll records
self-employment
☐ Current signed and dated income tax return and all Schedules**
☐ Records of earnings and expenses/business records
Unemployment Benefits
☐ Award letter/certificate
☐ Monthly benefit statement from NYS Department of Labor
☐ Printout of recipient’s account information from the
NYS Department of Labor’s website (www.labor.state.ny.us)
☐ Copy of Direct Payment Card with printout
☐ Correspondence from the NYS Department of Labor
Private Pensions/annuities
☐ Statement from pension/annuity
DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE
PROOF OF CURReNT INCOMe, OR INCOMe YOU MIGHT GeT IN THe FUTURe lIKe UNeMPlOYMeNT BeNeFITs OR a laWsUIT: You must provide a letter, written statement, or copy of check
or stubs, from the employer, person or agency providing the income. YOU dO NOT Need TO sHOW Us all OF THese dOCUMeNTs, only the ones that apply to you and the people living with you.
One proof for each type of income you have is required. Provide the most recent proof of income before taxes and any other deductions. The proof must be dated, include the employee’s name
and show gross income for the pay period. The proof must be for the last four weeks, whether you get paid weekly, bi-weekly, or monthly. It is important that these be current.
☐ Evidence of Continuous U.S. Residence prior to
January 1, 1972
The list below contains some of the most common United States Citizenship and Immigration Services (USCIS) forms used to show your immigration status.
This list is not all-inclusive. If you do not have one of these documents, please refer to the “How to Get Help” section of the instructions.
We need to see ONe of the following documents to prove both Immigration Status, Identity and your Date of Birth:
documents with * next to it also show date of birth
Immigration status/Identity
☐ I-551 Permanent Resident Card (“Green Card”)*
☐ I-688B or I-766 Employment Authorization Card*
** Income tax returns for other than self-employed may be used for
applications prior to April 1 of the following year.
If you are not a U.s. Citizen
☐ Lease/ letter/ rent receipt with your home address from landlord
☐ Utility Bill (gas, electric, phone, cable, fuel or water)
☐ Property tax records or mortgage statement
Immigration status, but require an additional Identity document
☐ I-94 Arrival/Departure Record*
☐ USCIS Form I-797 Notice of Action
Home address: This address must match the home address that you write in section a of the application. The proof must be dated within 6 months of when you signed the application.
DOH-4220B 5/13 (page 3 of 3)
NYS DOH
DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE
If you pay to have care for your children or parents while you work, provide one of the following:
☐ Written statement from day care center or other child/adult care provider
☐ Canceled checks or receipts that show your payments
Proof of health insurance, provide all that apply:
☐ Proof of current insurance (Insurance policy, Certificate of Insurance or Insurance Card)
☐ Health Insurance Termination Letter
☐ Medicare Card (Red, White and Blue Card)
Pregnant women only: proof of pregnancy, provide one of the following:
☐ Presumptive Eligibility Screening Worksheet for pregnant women
completed by a provider that tells us the expected date of delivery
☐ Statement from medical professional (such as a doctor or nurse
practitioner) with the expected date of delivery
☐ WIC Medical Referral Form that tells us the expected date of delivery
If you have medical bills in the last three months, provide all the following:
For determination of eligibility for medical expenses from the past three months:
☐ Proof of income for the month(s) in which the expense was incurred
☐ Proof of residency/home address for the month(s) in which the expense
was incurred
☐ Medical bills for last three months, whether or not you paid them
Resources (only if you are over 65 or disabled and have no children under 21 living with you):
☐ Bank account statements: checking, savings, retirement (IRA and Keogh)
☐ Stocks, bonds, certificates statements
☐ Copy of Life Insurance policy
☐ Copy of burial trust or fund burial plot deed or funeral agreement
☐ Deed for real estate other than residence
Proof of student status for college students if employed:
☐ Copy of schedule
☐ Statement from college or university
☐ Other correspondence from college showing student status
legal First, Middle, last Name
date of
Birth
Is this
person
applying
for health
insurance?
Is this
person
pregnant?
Is this
person the
parent of
an applying
child?
What is the
relationship
to the
person
in Box 1?
If this person has or had
public health coverage
in the past, check
the box that applies.
social
security
Number
(if you
have one)
*Race/
ethnic
Group
01
02
ACCESS NY HEALTH CARE Medicaid / Family Health Plus / Child Health Plus
PLEASE READ the entire application and INSTRUCTIONS before you fill it out. Print clearly in blue or black ink. An incomplete application cannot be processed and will result in a delay of a decision on your application.
Section A
Section B
Applicant’s Information Please tell us who you are and how to contact you.
legal First Name
another Phone #
street
street apt.#
apt.#
City
City
Name
street
City
state
state
state
Zip Code
Zip Code
Zip Code
County
apt.#
What language do You
Middle Initial legal last Name
Primary Phone #
Home Cell Work Other
Home Cell Work Other
speak? Read?
HOMe addRess
of the persons applying for health insurance
Check here if homeless
MaIlING addRess
of the persons applying for health insurance if different from above.
OPTIONal: If there is another person you would like to receive your
Medicaid notices, please provide this person’s contact information.
I want this contact person to:
Apply for and/or renew Medicaid for me
Discuss my Medicaid application or case, if needed
Get notices and correspondence
Phone #
Check all
that apply
Home Cell Work Other
DOH-4220 5/13 (page 1 of 8)
Household Information If you live in the household, start with yourself. If you do not, start with any adults who live in the household. List the full legal names of
the persons applying for or already receiving Medicaid, Family Health Plus or Child Health Plus and list the Id Number from their Benefit Card or health plan Id card. You must provide information
for household members including: parents, step-parents, and spouses. You may provide information for other household members (for example, a dependent child under the age of 21).
listing other household members may allow us to give you a higher eligibility level. Pregnant women and children under 19 may be eligible for health insurance regardless of immigration status.
Yes
No
Yes
No
Male
Female
Male
Female
Yes
No
Yes
No
Yes
No
What is the
Due Date?
Yes
No
What is the
Due Date?
SELF
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
This Person’s Mother’s Full Maiden Name
City of Birth
State of Birth
Country of Birth
This Person’s Mother’s Full Maiden Name
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
/ /
/ /
Full Maiden Name (person’s birth name before they were married)
NYS DOH (Continued on page 2)
SEND PROOF
Please mark one box that
indicates your current
Citizenship or Immigration status.
Not needed for
pregnant women
SEND PROOF
SEND PROOF
SEND PROOF
*Race/ethnic Group Codes (optional): a-Asian, B-Black or African-American, I- Native American or Alaskan Native, P- Native Hawaiian or other Pacific Islander, W-White, U-Unknown. Please also tell us if you are Hispanic or Latino-H
Effective 7/1/10, citizen children who provide a SSN are not required to provide identity or citizenship documentation if eligible for Child Health Plus.
Refer to the “documents Needed When You apply for Health Insurance” in the instructions on pages 1-3, “documentation Checklist for Health Insurance”, for a list of documents that prove Identity, Citizenship or Immigration status.
SEND PROOF
/ /
/ /
DOH-4220 5/13 (page 2 of 8)
NYS DOH
legal First, Middle, last Name
date of
Birth
Is this
person
applying
for health
insurance?
Is this
person
pregnant?
Is this
person the
parent of
an applying
child?
What is the
relationship
to the
person
in Box 1?
If this person has or had
public health coverage
in the past, check
the box that applies.
social
security
Number
(if you
have one)
*Race/
ethnic
Group
03
04
05
06
07
Household Information (Continued from previous page)
Section B
Yes
No
Male
Female
Yes
No
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
This Person’s Mother’s Full Maiden Name
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
Yes
No
What is the
Due Date?
/ /
This Person’s Mother’s Full Maiden Name
Yes
No
Male
Female
Yes
No
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
/ /
/ /
This Person’s Mother’s Full Maiden Name
Yes
No
Male
Female
Yes
No
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
/ /
This Person’s Mother’s Full Maiden Name
Yes
No
Male
Female
Yes
No
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
/ /
This Person’s Mother’s Full Maiden Name
Yes
No
Male
Female
Yes
No
Child Health Plus
Medicaid
Family Health Plus
ID Number from
Benefit Card/Plan Card,
if known:
U.S. Citizen
Immigrant/non-citizen
Enter the date you received
your immigration status
______/______/______
Month Day Year
Non-immigrant (Visa holder)
None of the above
Full Maiden Name (person’s birth name before they were married)
City of Birth
State of Birth
Country of Birth
/ /
Is anyone in your household a veteran?
Yes No If yes, name:
SEND PROOF
Please mark one box that
indicates your current
Citizenship or Immigration status.
Not needed for
pregnant women
*Race/ethnic Group Codes (optional): a-Asian, B-Black or African-American, I- Native American or Alaskan Native, P- Native Hawaiian or other Pacific Islander, W-White, U-Unknown. Please also tell us if you are Hispanic or Latino-H
Effective 7/1/10, citizen children who provide a SSN are not required to provide identity or citizenship documentation if eligible for Child Health Plus.
Refer to the “documents Needed When You apply for Health Insurance” in the instructions on pages 1-3, “documentation Checklist for Health Insurance”, for a list of documents that prove Identity, Citizenship or Immigration status.
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Yes
No
What is the
Due Date?
/ /
Yes
No
What is the
Due Date?
/ /
Yes
No
What is the
Due Date?
/ /
Yes
No
What is the
Due Date?
/ /
Name of Person Type of Income/source How Much? (before taxes) How Often? (weekly, monthly)
Name of Person Type of Income/source How Much? (before taxes) How Often? (weekly, monthly)
Name of Person Type of Income/source How Much? (before taxes) How Often? (weekly, monthly)
Name of Person Type of Income/employer Name How Much? (before taxes) How Often? (weekly, monthly)
Section C
Household Income
Write the types of money and the amount received by everyone listed in Section B and
earnings from Work: Includes wages, salaries, commissions, tips, overtime, self-employment. If you are self-employed check here: Check here if no earnings from work:
NYS DOH
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Unearned Income: Includes Social Security Benefits, disability payments, unemployment payments, interest and dividends, veterans’ benefits, Workers’ Compensation,
child support payments/alimony, rental income, pension, annuities and trust income. Check here if no unearned income:
Contributions: Money from relatives or friends, roomers or boarders (include money that anyone gives you each month to help meet living expenses). Check here if no contributions:
Other: Temporary (cash) Assistance, Supplemental Security Income (SSI) payments, student grants, or loans. Check here if none:
Child’s/adult’s name: How much? $ How Often? (weekly, every two weeks, monthly)
Child’s/adult’s name: How much? $ How Often? (weekly, every two weeks, monthly)
Child’s/adult’s name: How much? $ How Often? (weekly, every two weeks, monthly)
2. If there is no income listed above, please explain how you are living:
(For example: living with friend or relative)
1. Do you or any applying adult in Section B have no income?
No Yes Who? _____________________________________________________________
3. Have you or anyone who is applying changed jobs or stopped working in the last 3 months?
No Yes
If yes: Your last job was: Date ______/______/______ Name of Employer:
4. Are you or anyone who is applying a student in a vocational, undergraduate, or graduate program?
No Yes
If yes: Full Time Part Time Undergraduate Graduate Student’s Name:
5. Do you have to pay for childcare (or for care of a disabled adult) in order to work or go to school? No Yes
6. If you are not eligible for Medicaid or Family Health Plus coverage, you may still be eligible for the Family Planning Benefit Program. Are you interested in receiving coverage for Family Planning Services only?
No Yes
DOH-4220 5/13 (page 3 of 8)
DOH-4220 5/13 (page 4 of 8)
1. Does anyone who is applying have Medicare? No Yes If yes, include a copy of your card (red, white and blue card), for each Medicare beneficiary.
Complete the rest of this application and complete supplement a.
2. Does anyone who is applying already have other commercial health insurance, including long term care insurance? No Yes If yes, you must send a copy of the front and back of the insurance card with this application.
Name of Insured (primary) ____________________________________ Persons Covered _________________________________ Cost of Policy ____________ End date of coverage, if ending soon ______/_______/_______
Note: If you are applying for the Medicare Savings Program only (MSP), go to Section G. You do NOT need to complete Supplement A.
3. Is the parent/step-parent of any child applying a public employee who can get family coverage through a state health benefits plan? (see instructions)
No Yes
If yes, does the public agency where that person works pay all or part of the cost of the health plan? No Yes
4. In the past 6 months, has anyone lost or cancelled any type of health insurance that was provided through an employer? No Yes (If no, skip to question 5) If yes, what date did you lose coverage? ______/_______/_______
Your answer to this question will help us understand why people change their health insurance.
Why do the person(s) no longer have the health insurance? (Check only one)
1. The person who had the insurance no longer works for the employer that provided the insurance.
2. The employer stopped offering health insurance.
3. The employer stopped offering health insurance for the child(ren)
or stopped paying for health insurance for the child(ren) but continued to cover the working parent.
5. Does your current job offer health insurance? We may be able to help pay for it. No Yes If yes, a “Request for Information Employer Sponsored Health Insurance” form will be sent to you.
Section D
Section E
Health Insurance
You and your family may still be eligible even if you have other health insurance.
Housing Expenses
NYS DOH
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4. The cost of health insurance went up and it was no longer affordable.
5. Child Health Plus or Family Health Plus costs less than the insurance the person(s) used to have.
6. Child Health Plus or Family Health Plus offers better benefits than the insurance the person(s) used to have.
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Month Day Year
Month Day Year
1. Monthly housing payment such as rent or mortgage, including property taxes (just your share). $___________________
2. If you pay for water separately how much do you pay? $________________ How often do you pay? every month 2 times a year quarterly (4 times a year) once a year
3. Do you receive free housing as part of your pay? No Yes
1. Are you, or anyone who lives with you, and is applying, in a residential treatment facility or receiving nursing home care in a hospital, nursing home or other medical institution?
No Yes
If yes, finish completing this application aNd complete Supplement A.
2. Are you or anyone who lives with you blind, disabled or chronically ill? No Yes If yes, finish completing this application aNd complete Supplement A.
Note: If you are applying for the Medicare Savings Program only (MSP), go to Section G. You do not need to complete Supplement A.
Section F Blind, Disabled, Chronically Ill or Nursing Home Care These questions help us determine which program is best for the applicants.
If no one applying is Blind, disabled, Chronically Ill or in a Nursing Home please go to section G.
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