Form Doh-4328 - Medicare Savings Program Application (Page 2 of 2) in pdf

PAYMENT OF YOUR MEDICARE PREMIUM IS A MEDICAID BENEFIT

PENALTIES: I understand that my application may be investigated, and I agree to cooperate in such an

investigation. Federal and State laws provide for penalties of fine, imprisonment or both if you do not tell

the truth when you apply for Medicaid benefits or at any time when you are questioned about your

eligibility, or cause someone else not to tell the truth regarding your application or your continuing

eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your initial and continuing

eligibility for Medicaid or if you conceal or fail to disclose facts that would effect the right of someone for

whom you have applied to obtain or continue to receive Medicaid benefits; and such benefits must be

used by the other person and not for yourself.

CHANGES: I agree to inform the agency promptly of any change in my needs, income, property, living

arrangements or address to the best of my knowledge or belief.

SOCIAL SECURITY NUMBER (SSN): If you are applying for the Medicare Savings Program, you must

report your SSN, unless you are a pregnant woman. The laws requiring this are: 18NYCRR Sections

351.2, 360-1.2, and 360-3.2(j)(3); 42USC 1320b-7. SSNs are used in many ways, both within the local

social services districts and also between local social services districts and federal, state, and local

agencies, both in New York and in other jurisdictions. Some uses of SSNs are: to check identity, to identify

and verify earned and unearned income, to see if absent parents can get health insurance for applicants,

to see if applicants can get child support and to see if applicants can get money or other help.

CERTIFICATION OF CITIZENSHIP & IMMIGRATION STATUS: I certify, under the penalty of perjury, by

signing my name on this application, that I, and/or any person for whom I am signing is a U.S. citizen or

national of the United States or has satisfactory immigration status. I understand that information about

me will be submitted to the United States Citizenship and Immigration Services (USCIS) for verification of

my immigration status, if applicable. I further understand that the use or disclosure of information about

me is restricted to persons and organizations directly connected with the verification of immigration status

and the administration and enforcement of the provisions of the Medicaid program.

NON-DISCRIMINATION NOTICE: This application will be considered without regard to race, color, sex,

disability, religious creed, national origin, or political belief.

CERTIFICATION: In signing this application, I swear and affirm that the information I have given or will

give to the Department of Social Services as a basis for Medicaid is correct. I also assign to the

Department of Social Services any rights I have to pursue support from persons having legal responsibility

for my support and to pursue other third-party resources. I understand that Medicaid paid on my behalf

may be recovered from persons who had legal responsibility for my support at the time medical services

were obtained.

CONSENT: I understand that by signing this application/certification form I agree to any investigation

made by the Department of Social Services to verify or confirm the information I have given or any other

investigation made by them in connection with my request for Medicaid. If additional information is

requested, I will provide it.

Applicant/Representative

Signature X ______________________________________________________ Date _____________

Spouse Signature X _______________________________________________ Date _____________

Representative Address, Phone Number and Relationship ___________________________________________________

_____________________________________________________________________________________________________

If after reading and completing this form, you decide that you DO NOT want to apply for the

Medicare Savings Program please sign on the following line.

I consent to withdraw my application ___________________________________ Date ____________

SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION:

DATE:

EMPLOYED BY:

Eligibility Determined By Worker:

________________________ Eligibility Approved By: ________________________

(DATE)

CENTRAL/OFFICE

APPLICATION DATE

UNIT ID

WORKER ID

CASE TYPE

CASE NO

REUSE IND.

CASE NAME

DISTRICT

REGISTRY NO.

VER.

REASON CODE

PROXY:

Yes

Effective Date ___________ MA Disp.

Denial

Withdrawal

DOH-4328

(6/08) Reverse

Form Doh-4328 - Medicare Savings Program Application Page 2

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