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MAP-931B Agreement to Participate in Pay-In Program
MAP-931B Agreement to Participate in Pay-In Program.pdf
HRA Form for enrolling in Pay-In Program for Spend-down
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13 Sep, 2010
84 kb
Downloads: 8229
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Medicaid Alert - Pooled Trust Submissions
medicaidalert HRA 4-06.pdf
Medicaid Alert issued by NYC Human Resources Administration instructing HRA staff how to process applications and renewals for consumers with pooled supplemental needs trusts. Dated April 26, 2006.
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08 Sep, 2010
52 kb
Downloads: 5674
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NYC Medicaid Facts Alert - Pooled Trust Contributions Excluded
NYCMedicaidFactsAlert.pdf
Publication from NYC Human Resources Administration regarding exclusion from income budgeting of excess income contributed to a pooled supplemental needs trust (SNT). Dated May 2004.
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08 Sep, 2010
53 kb
Downloads: 7658
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HEAP Cooling Assistance Application Locations
Cooling Assistance NYC.pdf
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13 Jul, 2010
76 kb
Downloads: 4514
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Sample HRA QMB Recertification Form
DAB Renewal.pdf
Sample of new recertification form that specifically refers to QMB. Actual recertification form will be prepopulated with the QMB recipients information. In use as of January 2010.
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11 Jun, 2010
166 kb
Downloads: 58212
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MAP 2050J--Home Equity Statement
MAP-2050J Home Equity Statement_Fillable.pdf
This form must be submitted if Medicaid applicant owns a home (or coop etc).
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27 May, 2010
93 kb
Downloads: 3881
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Map 2050J--Declaration of Income or Support
MAP-2050A Declaration of Income or Support.pdf
This form is used by the NYC Medicaid Program. It allows the family member or friend of a Medicaid applicant providing in-kind income or support to the applicant to document the kind of support provided, when it began, and whether it would continue. The form must be signed by the person providing support and the Medicaid applicant.
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27 May, 2010
58 kb
Downloads: 19366
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Eliminatin of Face to Face Interview for Medicaid/Family Health Plus
MAP Alert Elimination of Face to Face.pdf
Describes program implications of elimination of face to face interview requirement 4/1/10.
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05 May, 2010
84 kb
Downloads: 4223
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HRA MICSA Medical Assistance Program Alert - April 3, 2008 - Processing Medicare Savings Programs Applications by Mail
MSP Applications Done Now by Mail 4 08.PDF
Implements a new procedure for applying for Medicare Savings Programs by mail. May only be used by people not receiving and not applying for Medicaid in addition to an MSP.
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14 Apr, 2010
112 kb
Downloads: 13720
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HRA HIPAA release 8_08 Spanish
HRA_9_08span.pdf
Fillable pdf
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21 Jul, 2009
316 kb
Downloads: 5420
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