Form Doh-4328 Draft - Medicare Savings Program Application/renewal printable pdf download

NEW YORK STATE DEPARTMENT OF HEALTH

Office of Health Insurance Programs

MEDICARE SAVINGS PROGRAM

APPLICATION/RENEWAL

(Please Print Clearly And Do Not Write In Dark Shaded Area)

(First Name)

M.I.

(Last Name)

HOME PHONE

APPLICANT

HOME ADDRESS

Street

Apt.

City

State

Zip Code

County

Is this a Shelter? Yes

Street/P.O. Box

Apt.

City

State

Zip Code

County

MAILING ADDRESS

(If different from above)

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, use attachment 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

Are you a U.S. Citizen or do you have satisfactory

__Yes

__ No

Signature of Applicant: __________________________________________

immigration status? Include Alien Number and Date of

Entry, if applicable.

Alien Number_____________________ Date of Entry_________________

Is your spouse a U.S. Citizen or have satisfactory

__Yes

__ No

Signature of Spouse: ___________________________________________

immigration status? Include Alien Number and Date of

Entry, if applicable.

Alien Number_____________________ Date of Entry_________________

APPLICANT’S MEDICARE INFORMATION

Do you have Medicare Part A?

__Yes

__ No

Effective Date: _______________________

Medicare # _________________________________ Do you have Medicare Part B?

__Yes

__ No

Effective Date: _______________________

SPOUSE’S MEDICARE INFORMATION, if applying Does spouse have Medicare Part A? __Yes

__ No

Effective Date: _______________________

Medicare # _________________________________ Does spouse have Medicare Part B? __Yes

__ No

Effective Date: _______________________

Do you or your spouse pay any health insurance premiums other than Medicare?

__Yes

__ No

Monthly Amount: ______________________

Do you or your spouse pay child/spousal support?

__Yes

__ No

Monthly Amount: ______________________

Are you requesting retroactive reimbursement of your Medicare premium?

__Yes

__ No

Do you or your spouse receive payments from or are named beneficiary of a trust? __ Yes __ No Who? _____________________

Value: $ __________

Do you or your spouse expect to receive a trust fund, lawsuit settlement, or income

__ Yes __ No Who? _____________________

Value: $ __________

from other source?

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?

How Often?

What Amount?

(attach an extra sheet if necessary)

(Name/source of Income)

(Weekly, two weeks,

monthly)

DEPENDING ON YOUR INCOME, THE AMOUNT OF YOUR RESOURCES MIGHT NOT BE USED TO DETERMINE YOUR ELIGIBILITY

FOR THE MEDICARE SAVINGS PROGRAM.

List all resources available to you or your spouse. Resources include but are not limited to all cash on hand, checking, savings, and

credit union accounts, safe deposit box, life insurance, stocks, bonds, savings bonds, certificates, or mutual funds. Also include any real

estate other than your primary residence, including income-producing, and non-income producing property, burial space, burial trust/fund,

IRA, Keogh, 401-K, and annuity.

Life Insurance

Cash on Hand: $

Real Estate: $

Face Value

Cash Value

Checking Account: $

Savings Account: $

Other Bank Account: $

Other Resource Value: $

Do you want to receive notices in

English Only

Spanish and English

DOH-4328

(Draft)

Form Doh-4328 Draft - Medicare Savings Program Application/renewal

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