NYS Dept of Health Medicaid Enrollment Instructions
This document provides important instructions for Medicaid enrollment and exchange integration for applicants who may be blind or visually impaired. It includes information on available notice options in alternative formats such as large print, data CD, audio CD, and braille. Additionally, it outlines the availability of applications for benefits administered by the New York State Medicaid Program in accessible formats.
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How do I fill this out?
To complete this form, follow the detailed instructions in each section carefully. Make sure to provide accurate and up-to-date information as requested. If you need assistance, refer to the contact information provided for your social services district.
How to fill out the NYS Dept of Health Medicaid Enrollment Instructions?
1
Check the type of mail you want to receive.
2
Return the form with your application.
3
Sign and date the form.
4
Print your first and last name.
5
Submit the form to the appropriate address.
Who needs the NYS Dept of Health Medicaid Enrollment Instructions?
1
Applicants for New York State Medicaid Program need this form to specify their mail preferences.
2
Individuals who require alternative formats for communication.
3
Authorized representatives assisting with the application process.
4
Blind or visually impaired applicants needing accessible information.
5
Social services districts processing applications for benefits.
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What are the instructions for submitting this form?
Submit the completed form along with your application to your social services district. If you need assistance or require another accommodation, contact your social services district directly. Ensure all sections are filled out accurately and provide your signature before submitting.
What is the purpose of this form?
The purpose of this form is to facilitate the enrollment process for the New York State Medicaid Program, especially for applicants who may be blind or visually impaired. It ensures that communication preferences for receiving notices in alternative formats are clearly stated. By completing and submitting this form, applicants can ensure they receive important information in a format that meets their accessibility needs. This form is also used to request large print, data CD, audio CD, or braille versions of Medicaid and Family Planning Benefit Program applications. Authorized representatives can also use this form on behalf of applicants to ensure their communication preferences are honored.
Tell me about this form and its components and fields line-by-line.
- 1. Mail Preferences: Check the type of mail you want to receive - large print, data CD, audio CD, or braille.
- 2. Return Instructions: Instructions on returning the form with your application.
- 3. Signature of Adult Applicant: Field for the adult applicant or authorized representative's signature.
- 4. Date: Field for the date of signing.
- 5. Print Name: Field for the applicant's first and last name.
What happens if I fail to submit this form?
Failure to submit this form can lead to delays in receiving important Medicaid information and benefits.
- Delayed Benefits: Without this form, processing your application may be delayed.
- Communication Barriers: Failure to indicate your preferred format may result in receiving information in an inaccessible format.
- Incomplete Application: Incomplete submission may lead to requests for additional information and further delays.
How do I know when to use this form?
- 1. Medicaid and Medicare Savings Program Applications: All applicants applying for these programs should complete this form.
- 2. Alternative Format Requests: Submit this form to request large print, data CD, audio CD, or braille formats.
- 3. Authorized Representative Submissions: Representatives must also complete this form when assisting applicants.
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