TERMS, RIGHTS AND RESPONSIBILITIES
By completing and signing this application, I am applying for
Medicaid. I understand that this application, notices and other
supporting information will be sent to the program(s) for which
I want to apply. I agree to the release of personal and ï¬nancial
information from this application and any other information needed
to determine eligibility for these programs. I understand that I
may be asked for more information. I agree to immediately report
any changes to the information on this application.
â¢ I understand that I must provide the information needed to
prove my eligibility for each program. If I have been unable to
get the information for Medicaid, I will tell the social services
district. The social services district may be able to help in getting
â¢ If I am applying at a place other than a local department of social
services, and my children are not found eligible for Medicaid
using this application, I can contact the local department of social
services to see if my children are eligible for Medicaid on some
â¢ I understand that workers from the programs for which family
members or I have applied may check the information given by me
for this application. The agencies that run these programs will keep
this information conï¬dential according to 42 U.S.C. 1396a (a) (7)
and 42 CFR 431.300-431.307, and any federal and state laws and
â¢ I understand that Medicaid, will not pay medical expenses that
insurance or another person is supposed to pay, and that if I am
applying for Medicaid, I am giving to the agency all of my rights to
pursue and receive medical support from a spouse or parents of
persons under 21 years old and my right to pursue and receive
third party payments for the entire time I am in receipt of beneï¬ts.
â¢ I will ï¬le any claims for health or accident insurance beneï¬ts or any
other resources to which I am entitled. I understand that I
have the right to claim good cause not to cooperate in using health
insurance if its use could cause harm to my health or safety or to
the health and safety of someone I am legally responsible for.
â¢ I understand that my eligibility for Medicaid will not be affected by
my race, color, or national origin. I also understand that depending
on the requirements of the program, my age, sex, disability or
citizenship status may be a factor in whether or not I am eligible.
â¢ I understand that if my child is on Medicaid, he or she can get
comprehensive primary and preventive care, including all
necessary treatment through the Child/Teen Health Program. I can
get more information on this program from the local department
of social services.
â¢ I understand that anyone who knowingly lies or hides the truth in
order to receive services under these programs is committing a
crime and subject to federal and state penalties and may have to
repay the amount of beneï¬ts received and pay civil penalties.
The New York State Department of Tax and Finance has the right
to review income information on this form.
SOCIAL SECURITY NUMBER
SSNs are required for all applicants, unless the person is pregnant
or a non-qualiï¬ed alien. SSNs are not required for members of my
household who are not applying for beneï¬ts unless the person is my
spouse and my eligibility depends on the amount of resources owned
by my spouse. I understand that this is required by Federal Law at
42 U.S.C. 1320b-7 (a) and by Medicaid regulations at 42 CFR 435.910.
SSNs are used in many ways, both within department of social
services (DSS) and between the DSS and federal, state, and local
agencies, both in New York and other jurisdictions. Some uses of
SSNs are: to c heck identity, to identify and verify earned and unearned
income, to see if non-custodial parents can get health insurance
coverage for applicants, to see if applicants can get medical support,
to see if applicants can get money or other help, and to verify
resources with ï¬nancial institutions for applicants and their
non-applying spouse. SSNs may also be used for identiï¬cation of
the recipient within and between central governmental Medicaid
agencies to insure pr oper services are made available t o the recipient.
Also, if I apply for other programs in this joint application, those
programs will have access to my SSN and could use it in the
administration of the program.
FOR MEDICAID APPLICANTS ONLY
â¢ Release of Educational Records
I give permission to the local department of social services and
New York State to obtain any information regarding the educational
records of my child(ren), herein named, necessary for claiming
Medicaid reimbursements for health-related educational services,
and to provide the appropriate federal government agency access
to this information for the sole purpose of audit.
â¢ Early Intervention Program
If my child is evaluated for or participates in the New York State
Early Intervention Program, I give permission to the local
department of social services and New York State to share my
childâs Medicaid eligibility information with my county Early
Intervention Program for the purpose of billing Medicaid.
â¢ Reimbursement of Medical Expenses
I understand that I have a right as part of my Medicaid application,
or later, to request reimbursement of expenses I paid for covered
medical care, services and supplies received during the three
month period prior to the month of my application. After the
date of my application, reimbursement of covered medical care,
services and supplies will only be available if obtained from
Medicaid enrolled providers.
MEDICAID MANAGED CARE
I have read how to ï¬nd out whether my county requires Medicaid
enrollees to join a health plan, and how to ï¬nd out what health plans
are available to me in Medicaid managed care. I/we also understand
that if I/we are found eligible for Medicaid and I/we are in a county
that requires Medicaid enrollees to be in a managed care health plan,
I/we will be enrolled in the health plan I/we chose unless that health
plan does not participate in Medicaid managed care.
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