DOH-4328 (8/17) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Health Insurance Programs
Medicare Savings Program Application
Please print clearly and do not write in the dark shaded area.
APPLICANT
NAMES
List your name first. Include aliases and maiden name. If necessary, attach an extra sheet to list all children.
INCOME
List below all available income such as: salary, wages, pension, social security, severance pay, rental or business income, etc. If necessary, attach an extra sheet
to list all sources of income.
First Name, Middle Initial, Last Name Home Phone
H
ome Address Street Apt. No. City State Zip Cod e County
*If under 18 years of age.
Race/Ethnic Affiliation Codes:
B
: Black, Not of Hispanic Origin W: White, Not of Hispanic Origin H: Hispanic A: Asian or Pacific Islander I: American Indian or Alaskan Native U: Unknown O: Other
Date of Birth Race/Ethnic Group
First Name, Middle Ini tial, Last Name (MM/DD/YY) Sex Social Security Number (See Codes Below)
Self
Spouse
Child*
Child*
I
s this a shelter? Yes No
Who Provides the Money? How Often?
Name of Applicant, Spouse, or Child Under 18 (Name/Source of Income) What Amount? (Weekly, Every Two Weeks, Monthly, Other)
Do you want to receive notices in: English Only Spanish and English
M
ailing Address Street/P.O. Box (If Different from Above) Apt. No. City State Zip Cod e County
Is your spouse a U.S. citizen? Yes No
If No, does your spouse have satisfactory immigration status? Yes No
Include alien number, date of status, and date entered country, if applicable.
Alien Number Date of Status (DOS) Date Entered Country (DEC)
S
pouse’s Medicare Number (From Red and Blue Medicare Card)
E
ffective Date Effective Date
Does your spouse have Medicare Part A? Yes No Does your spouse have Medicare Part B? Yes No
MEDICARE INFORMATION
Applicant’s Medicare Number (From Red and Blue Medicare Card)
Effective Date Effective Date
Do you have Medicare Part A? Yes No Do you have Medicare Part B? Yes No
Monthly Amount
Do you or your spouse pay any health insurance premiums other than Medicare? Yes No
Would you like us to consider providing retroactive reimbursement of your Medicare premium? Yes No
Who?
$
Monthly Amount
Do you or your spouse pay child/spousal support? Yes No
Who?
$
Value
Do you or your spouse receive payments from or are named beneficiary of a trust? Yes No
Who?
$
Are you a U.S. citizen? Yes No
If No, do you have satisfactory immigration status? Yes No
Include alien number, date of status, and date entered country, if applicable.
Alien Number Date of Status (DOS) Date Entered Country (DEC)
CITIZENSHIP INFORMATION
Applicant/Representative Signature Date
Representative Address
City State Zip Cod e
Phone Number Relationship
Spouse Signature Date
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.
SIGNATURES
INSTRUCTIONS
COMPLETE THE APPLICATION
Be sure to answer all the questions. If you are married and living with your spouse, you must complete both the “Self” and “Spouse” questions on the application
(even if the spouse is not applying for the MSP).
SIGN AND DATE THE APPLICATION
If both spouses are applying, both must sign the MSP application.
INCLUDE THE FOLLOWING VERIFICATION DOCUMENTS
Please review this list and submit the documents that you will need to provide in order for the Medicaid Program to determine if you are eligible for MSP. If you are
requesting retroactive reimbursement of your Medicare premiums, you must send proof of income for the previous three-months. If there is an applying spouse,
the spouse must also provide documentation.
• A photocopy of the front and back of your Medicare card.
• Proof of income: Paycheck stubs, letter from employer, income tax return, award letter for any unearned income benefit such as social security, unemployment,
o
r veteran’s benefit, or letter from renter, boarder or tenant.
• Health insurance premiums that you pay other than Medicare: Letter from employer, premium statement, or pay stub.
• Proof of date of birth: State driver’s license, U.S. birth certificate, permanent resident card (“green card”), or NYS Benefit Identification Card.
• Proof of residence: Lease/letter/rent receipt with your home address from your landlord, driver’s license (if issued in the past 6 months), utility bill (gas,
e
lectric, phone, cable, fuel or water), government ID card with address, property tax records or mortgage statement, or postmarked envelope or postcard
(cannot use if sent to a P.O. Box).
• If you are not a U.S. citizen, you must provide documents indicating your current immigration status.
Mail the application and required documentation to your local Department of Social Services (LDSS) or Human Resource Administration (HRA). To find the
address in your county: http://www.health.ny.gov/health_care/medicaid/ldss.htm
TERMS, RIGHTS AND RESPONSIBILITIES
By completing and signing this form, I am applying for the Medicare Savings Program. 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.
CHANGES
I agree to immediately report any changes to the information on this application.
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.
DOH-4328 (8/17) Page 2 of 2
If after reading and completing this form, you decide that you DO NOT want to apply for the Medicare Savings Program, please sign your name below:
I consent to withdraw my application:
Signature of Person Who Obtained Eligibility Information Date Employed By
Date Eligibility Determined By Worker Date Eligibility Approved By
Central/Office Application Date Unit ID Worker ID Case Type Case No. Reuse Ind.
Case Name District Registry No. Ver.
Effective Date Reason Code Proxy
Yes NoMA Disp. Denial Withdrawal
Applicant Signature Date
