Family Planning Benefit Program Application printable pdf download

NEW YORK STATE DEPARTMENT OF HEALTH

Family Planning Benefit Program Application

Office of Health Insurance Programs

Please print clearly. Please ask for help if there is anything you do not understand.

SECTION A

CONTACT INFORMATION

Tell us who you are and how to contact you.

First Name, Middle Initial, Last Name

Primary Language Spoken

Home Address Street

Apt. No.

City

State

Zip Code

County

If you do not want to receive mail or a benefit card at your home address for confidentiality purposes, please give a different address below.

Mailing Address Street (If Different)

Apt. No.

City

State

Zip Code

County

Phone Number(s) Where You Can Be Reached

Is Anyone in the Household a Veteran? If YES, list name:

SECTION B

HOUSEHOLD INFORMATION

List the names of people living with you who are applying for FPBP. You must list your spouse that lives with you even if your spouse is not applying.

If you live with others, such as your children, you may list them even if they are not applying.

FOR FPBP APPLICANTS ONLY

Is this Person

First Name, Middle Initial, Last Name

Date of Birth

Applying for Family

Race/Ethnic Group

(Use Another Page if You Need to List More People)

(MM/DD/YY)

Sex

Relationship to Person on Line 1

Planning Benefits?

Social Security Number

(See Codes)

Male

Yes

Self

Female

Male

Yes

Female

Male

Yes

Female

Male

Yes

Female

Race/Ethnic Group Codes (Optional):

B: Black or African American

A: Asian

W: White

H: Hispanic or Latino

I: American Indian or Alaskan Native

P: Native Hawaiian or Other Pacific Islander

U: Unknown

SECTION C

HOUSEHOLD INCOME

List the types of money and the amount received by anyone listed in Section B. Be sure to include earnings from work, child support payments, unemployment

benefits, interest, Social Security benefits, pensions, disability payments, money from relatives or friends or any other payments.

Type of Current Income

How Much Does the Person Receive?

How Often is the Income Received?

Name of Person Working or Receiving Money

(Example: Wages, UIB, SSA Benefits)

(Before Taxes)

(Weekly, Every Two Weeks, Monthly, Other)

If you have no income, please explain how you are meeting your needs (for example, living with friends or relatives), and if you are a student:

Do you have to pay for child care (or for care of a disabled adult) in order to work or go to school?

Yes

No If YES:

Name(s)

How Much?

How Often? (Weekly, Monthly)

SECTION D

CITIZENSHIP

This information is needed for all person(s) applying for family planning benefits.

All persons applying for Family Planning Benefits must submit original documentation of their citizenship and identity. If you have already done so, you do not

need to show us again at renewal. Your provider or worker will advise you as to what the acceptable forms of documentation are according to Federal guidelines.

Is everyone who is applying a U.S. citizen, national or Native American?

Yes

If NO, please give the following information for anyone applying for family planning benefits who are not U.S. citizens. Your answers to these questions will

be kept completely confidential.

Does This Person Belong to Any of the Categories

If A or B, On What Date Did the Person

First Name, Middle Initial, Last Name

Listed Below? Check the Appropriate Box.

Enter the United States? (MM/DD/YY)

None

A: Check A if the person is under one of the following categories:

B: Check B if the person is under one of the following categories:

• Legal Permanent

• Cuban/Haitian Entrant

• Some Battered

• Order of Supervision

• Covered by an Approved Immediate Relative Petition

Resident (Green

Immigrants and/or

• Withholding of

• Stay of Deportation

• Properly Filed or Granted Application for Adjustment of Status

Card Holder)

Children

Deportation

• Suspension of Deportation

• Has Lived Continuously in the United States Since Before

• Asylee

• Native American Born

• Parolee for at Least

January 1, 1972

• Voluntary Departure

in Canada Who is at

• Refugee

One Year

• Living in the United States with the Knowledge and Permission

Least 50% Native

• Deferred Action Status

• Amerasian

• Conditional Entrant

or Acquiescence of the USCIS and Whose Departure USCIS

American

• Parolee for Less Than One Year

Does Not Contemplate Enforcing

SECTION E

HEALTH INSURANCE

You may still be eligible even if you have other health insurance, especially if it does not cover family planning services, or if you have a good cause reason that

your health insurance should not be billed.

Does anyone in your household have

Medicaid,

Medicare,

Family Health Plus or

Child Health Plus? If YES, give the name of anyone with coverage:

Name(s)

Does anyone have other health insurance that covers a person applying for the Family Planning Benefit Program?

Yes

I Don’t Know If YES:

Name(s) of Person(s) Covered

Name of Subscriber/Policy Holder