New Medicaid Application Form

GIS 21 MA/22, dated 12/15/2021, advises that the Medicaid application form has been revised.

The new form, DOH-4220 (8/21) is attached to the GIS.  The new form also may be found by going to the New York State Department of Health website at: www.health.ny.gov

Click on Individuals/Families

Health Topics A-Z

M

Medicaid

Scroll down past What do I need to apply for Medicaid?

Under DOH-4220, click on the appropriate language

The old form had 4 photos on the front and was dated 3/15.  It was called, “Access NY Health Care Health Insurance Application for Children, Adults and Families.”

The new form has 3 photos on the front and is dated 8/21.  It is called, “Access NY Health Care Health Insurance for Older Adults, People With Disabilities and Certain Other Populations Application.”

Posted 12/19/2021