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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: 6085
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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: 11479
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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: 5515
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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: 3880
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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: 3591
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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: 4495
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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: 5929
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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.
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13 Apr, 2015
111 kb
Downloads: 3756
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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: 8510
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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
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09 Apr, 2015
74 kb
Downloads: 6326
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