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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: 3637
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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: 3726
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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: 3950
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MAP-58u List of Medicaid Offices
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
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13 Apr, 2015
377 kb
Downloads: 4655
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HIPAA Compliant Authorization Form 1-2013
HIPAA Compliant Authorization Form 1-2013.pdf
HIPAA form
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13 Apr, 2015
47 kb
Downloads: 10713
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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: 5053
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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: 3536
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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: 3237
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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: 4054
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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.
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13 Apr, 2015
882 kb
Downloads: 5514
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