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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: 59081
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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: 4344
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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: 20765
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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: 4655
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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: 14400
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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: 5893
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2009 Air Conditioner Application
2009 heat_health update_ac program final 051909 (2).pdf
NYC Dept. of Health and NYC Dept. for the Aging 2009 Application
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24 Jun, 2009
138 kb
Downloads: 4394
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HRA Medicaid E-Fax Spend-down Announcement
E-Fax_Flyer4_(4).doc
May 2009 announcement that HRA Medicaid program now accepts submission of medical bills by fax for people meeting spend-down.
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02 Jun, 2009
38 kb
Downloads: 7584
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Form MAP-252F - AIDS or AIDS Related Complex Medical Report
MAP-252F AIDS Medical Report.pdf
Addendum to Form LDSS-486T. This form is used by NYC HRA to establish that someone is disabled by reason of HIV/AIDS. Rev. 6/25/03.
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29 May, 2009
293 kb
Downloads: 4848
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HRA Medicaid Alert: Pooled Trust Submissions
HRA Medicaid Alert SNT 4-26-06.pdf
Dated 4/26/06.
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29 May, 2009
47 kb
Downloads: 7074
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