NY Health Access About Us   |   Contact Us Empire Justice Center Legal Aid Society NYLAG WNYLC
New York City Government
HIPAA Compliant Authorization Form 1-2013 Download
HIPAA Compliant Authorization Form 1-2013.pdf
HIPAA form
13 Apr, 2015 47 kb Downloads: 10114
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: 4619
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: 3186
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: 2925
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: 3709
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: 5040
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: 3033
Notice of Permanent Placement Medicaid Managed Care Download
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: 6833
MAGI Consumers Long Term Eligibility Rules Download
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: 5522
8 Helpful hints for accurate completion of the medical request for home care (M11Q) Download
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: 4994
Prev Next
... 5 6 7 8 9 10 11 12 13 14 ...

This site provides general information only. This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelpny.org. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information. To report a dead link or other website-related problem, please e-mail us.