Form Doh-4328 - Medicare Savings Program Application

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NEW YORK STATE DEPARTMENT OF HEALTH
Office of Health Insurance Programs
MEDICARE SAVINGS PROGRAM
APPLICATION
(Please Print Clearly And Do Not Write In Dark Shaded Area)
First Name
M.I.
Last Name
HOME PHONE
APPLICANT
Street
Apt.
City
State
Zip Code
County
HOME ADDRESS
Is this a Shelter? Yes __ No__
Street/P.O. Box
Apt.
City
State
Zip Code
County
MAILING ADDRESS
(If different from above)
6
NAMES (List your name first. Include aliases and maiden name)
First
M.I.
Last
Date Of Birth
Sex
Social Security Number
Race/Ethnic
Code
SELF
SPOUSE
CHILD*
*
If under 18 years of age. Attach extra sheet if necessary to list additional children.
B - Black, not of Hispanic origin
W - White, not of Hispanic origin
H – Hispanic
U - Unknown
Race/Ethnic affiliation codes:
A - Asian or Pacific Islander
I - American Indian/Alaskan Native
O – Other
__Yes
__No
Are you a U.S. Citizen?
If No, do you have satisfactory immigration
Alien Number
_____________________
__Yes
__No
status? Include Alien Number, Date of
Date of Status (DOS)
_____________________
Status, and Date Entered Country, if
applicable.
Date Entered Country (DEC) _____________________
Is your spouse a U.S. Citizen?
__Yes
__No
If No, does your spouse have satisfactory
Alien Number
_____________________
immigration status? Include Alien Number,
__Yes
__No
Date of Status (DOS)
_____________________
Date of Status, and Date Entered Country,
if applicable.
Date Entered Country (DEC) _____________________
APPLICANT’S MEDICARE INFORMATION
Medicare # ____________________________(From red and blue Medicare card)
Do you have Medicare Part A?
__Yes __No
Effective Date ___________________________
Do you have Medicare Part B?
__Yes __No
Effective Date ___________________________
SPOUSE’S MEDICARE INFORMATION, if applying
Medicare # ___________________________(From red and blue Medicare card)
Does spouse have Medicare Part A? __Yes __No
Effective Date __________________________
Does spouse have Medicare Part B?
__Yes __No
Effective Date __________________________
Would you like us to consider providing retroactive reimbursement of your Medicare premium? __Yes __No
Do you or your spouse pay any health
insurance premiums other than Medicare?
__Yes __No Who? __________________________ Monthly Amount $______________
Do you or your spouse pay child/spousal
support?
__Yes __No Who? __________________________ Monthly Amount $______________
Do you or your spouse receive payments
from or are named beneficiary of a trust?
__Yes __No Who? __________________________ Value $______________
List below all available income such as: salary, wages, pension, social security, severance pay, rental or business income, etc.
Names of Applicant, Spouse, or Child under 18
Who Provides the Money?
What Amount?
How Often?
(Attach an extra sheet if necessary)
(Name/source of Income)
(weekly, two weeks, monthly)
$
$
$
Do you want to receive notices in:
__ English Only
__ Spanish and English
DOH-4328
(6/08)

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