Form Doh-2794c - Adap Plus Insurance Continuation (Apic) Application
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1
2NEW YORK STATE DEPARTMENT OF HEALTH
U
C
P
NINSURED
ARE
ROGRAMS
Empire Station, PO BOX 2052
ADAP Plus Insurance Continuation (APIC) Application
Albany, NY 12220
The ADAP Plus Insurance Continuation (APIC) program is one of the services offered by the New York State Uninsured Care
Programs. The purpose of the APIC program is to pay health insurance premiums on behalf of ADAP eligible participants.
If you have any questions about completing this application, please contact our hotline at 1-800-542-2437.
APIC P
R
:
ROGRAM
EQUIREMENTS
If you are not enrolled with ADAP, you must fill out the Uninsured Care Programs (ADAP) Application. (Form DOH2794)
You must meet all ADAP eligibility requirements: New York State residency, and certain medical, income, and asset criteria.
You are paying for, or will need to pay for, your insurance premiums and cannot afford them.
Your policy has full prescription drug coverage and outpatient care is among the covered benefits.
T
I
P
C
:
YPES OF
NSURANCE
OLICIES
OVERED
COBRA - COBRA is an extension of health insurance coverage through former employment, where the person pays the cost of the
premium to continue coverage.
DIRECT PAY – Insurance policy purchased directly from an Insurance Company.
MEDICARE PART D - Insurance policy someone received by enrolling in a Medicare Prescription Drug Plan. For APIC to pay
your Medicare Part D premium, your Plan must bill you directly rather than deduct the payment from your Social Security
check.
Please review the entire application and fill out completely or processing will be delayed.
A. Y
I
:
B. P
H
I
(
):
OUR
NFORMATION
OLICY
OLDER
NFORMATION
IF DIFFERENT
Your Name:
Name:
ADAP ID Number (If Applicable):
Relationship:
Mailing Address:
Mailing Address:
Social Security Number:
-
-
Social Security Number:
-
-
Date of Birth:
/
/
Date of Birth:
/
/
Daytime Phone: (
)
-
Daytime Phone: (
)
-
Other Phone:
(
)
-
Other Phone:
(
)
-
Alternate Contact:
Relationship:
(Person to speak on your behalf - Family Member, Friend, Social Worker)
Phone:
(
)
-
C. B
I
:
ACKGROUND
NFORMATION
If yes, provide recent income information
(e.g. current pay stubs)
Yes
1) Are you currently employed?
If no, provide supporting documentation
(e.g. unemployment paperwork, current
No
SSD award letter, or letter of support)
2) Are you currently getting Health
Yes
If yes, is the employer contributing at least 50% of the premium?
Insurance through an employer?
No
Yes
No
(Proof Required – e.g. letter from employer)
Yes
If yes, you must send a copy of the COBRA paperwork which you received
3) Is this a COBRA Policy?
No
from the employer.
4) Is this a Direct Pay Policy?
Yes
If yes, you must include a copy of the most recent premium invoice showing
(Individual or Family)
amount currently due.
No
5) Is this a Medicare Part D Policy?
Yes
If yes, you must include a copy of your most recent premium invoice showing
(Prescription Drug Plan)
No
amount currently due.
D. I
C
I
:
Please obtain and send a copy of the front and back of your insurance cards.
NSURANCE
OMPANY
NFORMATION
Insurance Company Name:
Effective Date on Policy:
/
/
Address:
Policy Number:
Group Number:
Member Services Contact
:
Member Services Phone: (
)
-
(If Known)
DOH – 2794C (04/06) Page 1 of 2
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