![]() ![]() Information About Parents or Spouses Not Living in the Household (MAP-2097V): ![]() Medicaid Authorized Representative Designation/Change Request (DOH-5247) These forms may be needed for legally responsible relatives or to declare or change an authorized representativeĪpplicant/Recipient Declaration Concerning LLR Income-Resources (MAP-2161) Guide to Complete Your Medicaid Renewel Forms Instructions to Complete the Disabled, Aged, and Blind (DAB) Renewel Notification Form (MAP-2096P) Other documents may be used, even if not on the list. These guides don't mention every type of document. These guides help you fill out your Medicaid Renewal and give examples of documents you can use to give proof of information we need to decide on help for you. Clients can also submit the renewal electronically on ACCESS HRA. Clients should respond to the renewal received in the mail. You can apply online with ACCESS HRA Renewals Call the HRA Medicaid Helpline at 88 for more information. Clients not currently enrolled in Medicare must do so as a condition of eligibility. Clients whose citizenship status is not verified through data sources will also be given an opportunity to submit documents. If clients are unable to submit documentation at the time of application, the application will be deferred to give clients an opportunity to submit the documents. If immigration documents do not verify identity and/or citizenship, then copies of documents that prove identity/citizenship must still be submitted. New ApplicationsĬlients must provide proof of residency, identity, income, and immigration status. You can also find fact sheets and brochures to better understand your health insurance and coverage options under ACA. HRA's Office of Citywide Health Insurance Access also has resources for individuals and small businesses who want to learn more about public and private health insurance, including the Affordable Care Act. Other consumers must apply to the NY State of Health at nystateofhealth.ny.gov or by calling 85. Request an application for Medicaid Housekeeping Services or ask home care questions by calling the CASA Office in your borough. The documentation should also be submitted with the MAP-751W. Medicaid clients who have case changes that require additional documentation should use the MAP-751W form below. Clients can also use the MAP-751K form below to make this change and fax it to 91.Ĭonsumer/Provider Request to Change Information on File (MAP-751k)Ĭonsumer/Provider Request to Change Information on File (MAP-751W) Medicaid clients who have lost their EBT cards and have a change of address, should contact the Medicaid helpline to update their contact information at 88 to update their address. Call the HRA Medicaid Helpline at 1-88 for more information or visit a Medicaid Office to apply. HRA accepts applications from residents who are age 65 or over, persons of any age who are living with a disability or blindness, persons who are in receipt of Medicare and are not a parent or caretaker relative of minor children, and former foster young adults under age 26. HRA's Medical Assistance Program can help New Yorkers who qualify enroll in public health insurance programs like Medicaid. ![]() Health Assistance Health Insurance Options ![]()
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