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HSCP-3047b MLTC Nursing Home Eligibility Determination Cover Sheet
HCSP-3047b 1-26-2015.pdf
This is the cover sheet to used for MLTC NHED
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13 Apr, 2015
55 kb
Downloads: 5409
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HCSP-3047a MLTC/PRU
HCSP-3047a MLTC-PRU 1-26-15.pdf
This is the MLTC Provider Relations Unit cover sheet to be used
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13 Apr, 2015
47 kb
Downloads: 3516
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HCSP 3026 ALP Medicaid Cover Sheet
HCSP-3026 HCSP Cover Sheet for ALP-MLTC 1-26-2015.pdf
This is the cover sheet for HRA-ALP Medicaid Cover Sheet
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13 Apr, 2015
44 kb
Downloads: 3604
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Notice of Admission/Discharge for the Assisted Living Program
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
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13 Apr, 2015
44 kb
Downloads: 3832
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15-INF-03 Informational Letter Personal Needs Allowance in Non-Medical & Medical Facilities
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.
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13 Apr, 2015
302 kb
Downloads: 3167
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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.
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13 Apr, 2015
236 kb
Downloads: 4922
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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
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13 Apr, 2015
86 kb
Downloads: 3417
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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
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13 Apr, 2015
142 kb
Downloads: 3131
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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
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13 Apr, 2015
334 kb
Downloads: 3937
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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.
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13 Apr, 2015
36 kb
Downloads: 7258
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