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Notice of Admission/Discharge for the Assisted Living Program Download
HCSP 3027 1-26-2015.pdf
This form is to be mailed to Home Care Services Program once a client is admitted or discharged from Assisted Living Programs
13 Apr, 2015 44 kb Downloads: 973
MAP-58u List of Medicaid Offices Download
MAP-58u Where To Apply.pdf
This is a list of Medicaid Offices throughout NYC's 5 boroughs, along with a list of MICSA/MAP sites with certified application counselotrs
13 Apr, 2015 377 kb Downloads: 1353
Spousal Refusal Form - Suffolk County Download
Spousal Refusal Form - suffolk county.doc
This is the spousal refusal form for Suffolk County residents
13 Apr, 2015 25 kb Downloads: 2599
15-INF-03 Informational Letter Personal Needs Allowance in Non-Medical & Medical Facilities Download
15-INF-03 Informational Letter Personal Needs Allowance in Non-Medical and Medical Facilities.pdf
This informational letter provides social services districts with updated charts that represent the monthly Personal Needs Allowance, PNAs, for residents of non-medical facilities the PNAs in medical facilities.
13 Apr, 2015 302 kb Downloads: 601
MAP-909E DAB Renewal Redacted Download
MAP-909E DAB Renewal (8-2011) redacted.pdf
This is a redacted form that can act as a guide as for Disabled, Aged, & Blind client renewals.
13 Apr, 2015 1.88 mb Downloads: 1783
MAP-259H Consumer Intent to Return/Not Return Home Download
MAP-259H Intent to Return Home 2008-06-20.pdf
This form is used when a client enters a residential facility and makes a determination that he/she will either return or not return home.
13 Apr, 2015 236 kb Downloads: 1380
Agreement to Participate in the Medicaid Pay-In Program Download
MAP-931B Agreement to Participate in Pay-In Program searchable pdf.pdf
This is the form in both English & Spanish agreeing to participate in the Medicaid Pay-In Program
13 Apr, 2015 86 kb Downloads: 744
Optional Pay-In Program for Individuals with Excess Income Download
MAP-931A Optional Pay-In Program searchable pdf.pdf
This explains the Excess Income Program for clients whose incomes exceeds the Medical Assistance income limits
13 Apr, 2015 142 kb Downloads: 582
Notice of Acceptance of your Medical Assistance Application/Recertification Download
This is a redacted MAP-259p form to act as a guide for purposes of Medical Assistance application/recertification
13 Apr, 2015 334 kb Downloads: 868
Notice of Renewal of your Public Health Insurance Coverage Download
MAP 2088v_redacted.pdf
This is a redacted notice of renewal of public health insurance coverage to act as a guide to help clients fill out their renewals.
13 Apr, 2015 882 kb Downloads: 682
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