Access NY Health Care Application (DOH 4220) 4220 02ma004

User Manual: 4220

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WGIUPD
GIS 02 MA/004

GENERAL INFORMATION SYSTEM
DIVISION: Office of Medicaid Management

2/20/02
PAGE 1

TO:

Local District Commissioners, Medicaid Directors, Public Assistant

FROM:

Kathryn Kuhmerker, Deputy Commissioner
Office of Medicaid Management
Access NY Health Care Application (DOH-4220)

SUBJECT:

EFFECTIVE DATE:
CONTACT PERSON:

Immediately
Upstate: Local District Liason (518)474-8216
NYC: (212)268-6855

The new single health insurance application, Access NY Health Care (DOH4220) which was introduced on November 2, 2001 in 01 OMM/ADM-6 has been
posted on the website at www.health.state.ny.us/nysdoh/fhplus/application.
htm.
This new integrated application form is intended to simplify the
application process for both children and adults who wish to apply for the
CHPlus A and B, FHPlus/Medicaid, PCAP and WIC programs.
The website tells
individuals that they can print the application and use it.
This message is to clarify that local districts should accept and process
DOH-4220’s which have been downloaded from the Department of Health website,
as well as the color, printed version of the form.
The black and white
version of the DOH-4220 downloaded from the website is considered an official
version of the form, and an acceptable alternative to the color version.
For applicants who apply directly at the LDSS, local districts were
strongly encouraged to use the new DOH 4220 joint application form, but were
given
the
option
to
use
the
LDSS-2921,
“Application
for
Public
Assistance/Medical Assistance/Food Stamp Services”.
All districts must be
able to accept and process DOH-4220’s that are forwarded to the district
directly from an approved FHPlus enrollment facilitator.
Please direct any questions to your Local District Liaison at the numbers
listed above.
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