Form Doh-2794c - Adap Plus Insurance Continuation (Apic) Application Page 2

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E. P
I
:
Payment Information Will Depend on Your Type of Insurance Plan.
AYMENT
NFORMATION
• For COBRA, payment is often not made directly to the insurance company. Please contact your employer or COBRA
administrator to determine where the payment should be sent (if the information is not on the COBRA letter). Send us a copy of
your COBRA paperwork.
• For Direct Pay, Send us the most recent invoice showing the current balance due.
For Payroll Deduction, information entered must be the employer’s name, address, contact, and phone number for us to verify the
insurance payment. Send us a copy of the most recent pay stub.
Company Name:
Contact Person:
Company Address:
Contact Phone: (
)
-
Payment is Due:
Monthly
Quarterly
Company Federal Tax ID #:
Other:
Payment Amount: $
Payment Due Date:
/
/
You May Need to Call Your Insurance Company to Complete the Following P
B
I
:
OLICY
ENEFIT
NFORMATION
F. P
C
C
Insurance Company Name:
RIMARY
ARE
OVERAGE
$ _________________
If yes, what are they?
Do you have co-payments for your Doctor or clinic
Yes
Percentage: _________%
visits?
No
Out of pocket expenses: $_________
If no, what is your benefit?
Lifetime Max: ___________________
Yes
Do you have an annual deductible?
If yes, what is it?
$ _________________________
No
Yes
Do you have out-of-network benefits?
If yes, what are they?
$ _________________________
No
Name of Carrier:
G. P
C
RESCRIPTION
OVERAGE
Generic = $__________
Do you have co-payments for your prescription
Yes
If yes, what are they?
Preferred Brand = $__________
drugs at the retail pharmacy?
No
Non-Preferred Brand = $_________
Does your insurance company only cover a
Yes
If yes, what percentage of costs is covered?
______________%
percentage of your prescription drug costs?
No
Yes
Do you have an annual deductible?
If yes, what is it?
$__________________________
No
Generic = $__________
Are you able to get your prescribed medications by
Yes
If yes, what are the
Preferred Brand = $__________
mail order? (3 month supply)
No
co-payments:
Non-Preferred Brand = $_________
Yes
If yes, are all drugs covered by your mail order?
If no, what is excluded?
___________________________
No
If yes, what is the amount?
$__________________________
Does your Prescription Plan have an annual
Yes
maximum (or cap) on your prescription coverage?
No
Annual Cap
Lifetime Cap
I certify that the above information is true and accurate to the best of my knowledge and I understand the following:
This information is being given in connection with the receipt of federal funds by the State of New York.
Program officials will verify the information on this form.
If I deliberately misrepresent information on this application or the Uninsured Care Programs (ADAP) Application, I may be required to repay
benefits provided to me and I may be prosecuted under applicable State & Federal Statutes.
I authorize the New York State Department of Health, Uninsured Care Programs, to obtain any information from the individuals or companies I
have indicated on this form regarding my private health insurance coverage, including information regarding payee address, covered benefits and
the status of my policy which will be used to determine if the Department will pay my Health Insurance Premiums.
I hereby apply for benefits under the Uninsured Care Programs and consent for my information to be used and disclosed as necessary for the
purposes of my treatment, for payment of healthcare services, payment of healthcare premiums and for the healthcare operations of the
Program.
S
D
F
:
(If you are not the policy holder, both you and the policy holder need to sign and date this form.)
IGN AND
ATE THIS
ORM
________________________________________________
__________
____________________________________________
________
Signature of Applicant (or legal guardian if unable to sign)
Date
Signature of Policy Holder (if different than the applicant)
Date
Keep a copy of this form for your records and mail the original form and all documentation to:
Uninsured Care Programs, Empire Station, PO BOX 2052, Albany, NY 12220-0052
If you have questions or need more information please call us at 1-800-542-2437 between 8:00 AM and 5:00 PM Monday through Friday.
DOH – 2794C (04/06) Page 2 of 2

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