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Medicaid
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: 1283
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: 2382
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: 532
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: 1553
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: 1285
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: 674
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: 511
Notice of Acceptance of your Medical Assistance Application/Recertification Download
MAP-259p_redacted.pdf
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: 782
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: 587
Formerly Incarcerated Individuals Reactivation Transmittal Download
map-3103 Formerly Incarcerated Individuals Reactivation Transmittal.pdf
This form was uploaded by NYC HRA on 2/20/15 to help formerly incarcerated individuals reactivate their medicaid account once they have been released.
13 Apr, 2015 111 kb Downloads: 576
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