New York Health Access - Files - New York City Government

New York City Government

	HIPAA Compliant Authorization Form 1-2013 HIPAA Compliant Authorization Form 1-2013.pdf HIPAA form
	13 Apr, 2015 47 kb Downloads: 9921

	MAP-259H Consumer Intent to Return/Not Return Home 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: 4482

	Agreement to Participate in the Medicaid Pay-In Program 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: 3078

	Optional Pay-In Program for Individuals with Excess Income 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: 2824

	Notice of Acceptance of your Medical Assistance Application/Recertification 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: 3601

	Notice of Renewal of your Public Health Insurance Coverage 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: 4763

	Formerly Incarcerated Individuals Reactivation Transmittal 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: 2933

	Notice of Permanent Placement Medicaid Managed Care MAP-2159i Notice of Permanent Placement Medicaid Managed Care.pdf NYC HRA uploaded this form on 4/3/15 to be used for clients requiring permanent placement under Medicaid's managed care plan.
	13 Apr, 2015 36 kb Downloads: 6627

	MAGI Consumers Long Term Eligibility Rules 2014-10-24 MAGI Consumers Long Term Eligibility Rules.pdf long term eligibility rules for individuals who are eligible for Medicaid under a Modified Adjusted Gross Income (MAGI) eligibility group
	09 Apr, 2015 74 kb Downloads: 5397

	8 Helpful hints for accurate completion of the medical request for home care (M11Q) 2014-12-09 8 Helpful HInts re Completion M11q.pdf 8 helpful hints for accurate completion of the medical request for home care (M11Q)
	09 Apr, 2015 61 kb Downloads: 4861

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