Family Planning Benefit Program Application (Page 2 of 2) in pdf

TERMS, RIGHTS AND RESPONSIBILITIES

By completing and signing this application, I am applying for the Family Planning Benefit Program (FPBP). I agree to the release of personal and financial information from this

application and any other information needed to determine eligibility. I understand that I may be asked for more information. I agree to immediately report any changes to the

information on this application.

I understand that I must provide the information needed to prove my eligibility. If I have been unable to get the information, I will tell the social services district. The social services

district may be able to help in getting the information.

I understand the FPBP may check the information given by me for this application without my confidentiality being compromised. The state, social services district and provider who assist

in completing this application will keep this information confidential according to 42 U.S.C. 1396a(a)(7) and 42 CFR 431.300431.307, and any federal and state laws and regulations.

I understand that my eligibility for this program will not be affected by my race, color, disability, sex, or national origin. I also understand that depending on the requirements of this

program, my age or citizenship status may be a factor in whether or not I am eligible.

I understand that anyone who knowingly lies or hides the truth in order to receive services under this program is committing a crime and subject to federal and state penalties

and may have to repay the amount of benefits received and may also be given civil penalties.

I understand that I must provide original documentation of my citizenship and identity to the Social Services District or to the Family Planning Provider on behalf of the

local district to receive Family Planning Benefits. I also understand that the social services district can assist me in determining my status and obtaining any necessary

documents if I request help. Once I have provided my original documents for the worker to document my citizenship and identity, I will not have to provide them again.

If I am filling out this form as a mailin renewal, and have not yet provided these original documents, I should not mail them, but should go to the local district office

to show them to a worker, so they may record the originals have been seen. Social Services will not keep my original documents.

Immigration: United States Citizenship and Immigration Services (USCIS) has said that enrollment in Medicaid CANNOT affect a person’s ability to get an identification card,

become a citizen, sponsor a family member or travel in and out of the country (except if Medicaid pays for long term care in a place like a nursing home or a psychiatric hospital).

The State will not report any information on this application to the USCIS.

ASSIGNMENT OF RIGHTS FOR MEDICAL SUPPORT AND THIRD PARTY PAYMENT

I understand that FPBP does not pay medical expenses that insurance or another person is supposed to pay, unless there is good cause not to use other insurance. All persons applying

for FPBP are required to give to the Medicaid agency any rights they may have to medical support or other insurance payments for family planning services, unless they request and

receive a good cause exemption. When I sign this application for myself, or for another person for whom I can legally give away rights, I am giving to the Medicaid agency all of my

rights to receive medical support and third party payments for family planning services for the entire time I am on Medicaid.

REIMBURSEMENT OF MEDICAL EXPENSES

After the date of my application, reimbursement of covered family planning services and supplies will only be available if obtained from Medicaidenrolled providers.

SOCIAL SECURITY NUMBER (SSN)

I understand that I must give my SSN in order to receive FPBP. This is required by section 1137(a) of the Social Security Act and the Medicaid regulations (42 CFR 435.910 and 42 U.S.C.

1320b7(a) ). The FPBP will use the SSN to verify my income, eligibility, and the amount of medical assistance payments made on my behalf. The information may be matched with the

records in other agencies, such as the Social Security Administration and/or the Internal Revenue Service.

CONFIDENTIALITY STATEMENT

All of the information you provide to us will remain confidential. The only people who will see this information are the state or local agencies and the person assisting you in completing

the application that need to know this information in order to determine if you are eligible. The person helping you with this application cannot discuss the information with anyone,

except a supervisor or the state or local agencies that need this information.

RELEASE OF MEDICAL INFORMATION

I consent to the release of any medical information about me and any members of my family for whom I can give consent by: my Primary Care Provider, any other health care provider

or the New York State Department of Health (SDOH) and any health care provider involved in caring for me or my family, as reasonably necessary for my providers to carry out

treatment, payment, or health care operations, to SDOH and other authorized federal, state, and local agencies for purposes of administration of the Medicaid program. I also agree

that the information released may include HIV, mental health or alcohol and substance abuse information about me and members of my family to the extent permitted by law.

I certify that I have read and understand the Terms, Rights and Responsibilities above. I certify under penalty of perjury that everything on this application is the truth

as best I know.

Date ____________ Applicant’s Signature ___________________________________

Spouse’s Signature (If Applying) ________________________________

DECLINATION OF MEDICAID AND FAMILY HEALTH PLUS ELIGIBILITY DETERMINATIONS

I, ________________________________________________, have been informed of the enhanced benefits and additional services and coverage available under

Medicaid and Family Health Plus. I choose not to apply for Medicaid and Family Health Plus at this time, and have requested an eligibility determination for the Family

Planning Benefit Program only. I understand that I may apply for these other programs at any time in the future if I wish.

Date ____________ Applicant’s Signature ____________________________________ Provider/Medicaid Staff Signature _______________________________

IF AFTER READING AND COMPLETING THIS FORM, YOU DECIDE THAT YOU DO NOT WANT TO APPLY FOR THE FAMILY PLANNING BENEFIT PROGRAM, please SIGN your name below:

I consent to withdraw my application, and understand that I may reapply at any time:

Date ____________ Applicant’s Signature _____________________________________________________________________________________________

FOR OFFICE USE ONLY

To Be Completed By the Person Assisting With the Application:

Signature of Person Who Obtains Eligibility Information_________________________________________ Employed By ___________________________________

Have Original Documents Been Seen for Citizenship/Identity?

Yes

No (Applied For)

To Be Completed By the Local Social Services District:

Eligibility Determined By _______________________________________________________________________________________ Date _________________

Eligibility Approved By ________________________________________________________________________________________ Date _________________

Center Office: ____________ Application Date: ____________ Unit ID: ________________ Worker ID: ___________ Version: _____________

Case Name: _____________ District: ___________________ Case Type: ______________ Case No: ____________

Effective Date: ___________ MA Disposition Reason Code: ___________________________ Proxy: ______________ Reg. No._____________

DOH4282 (9/09) Page 2 of 2

Family Planning Benefit Program Application Page 2

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