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

User Manual: 4220

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WGIUPD GENERAL INFORMATION SYSTEM 2/20/02

DIVISION: Office of Medicaid Management PAGE 1

GIS 02 MA/004

TO: Local District Commissioners, Medicaid Directors, Public Assistant

FROM: Kathryn Kuhmerker, Deputy Commissioner

Office of Medicaid Management

SUBJECT: Access NY Health Care Application (DOH-4220)

EFFECTIVE DATE: Immediately

CONTACT PERSON: Upstate: Local District Liason (518)474-8216

NYC: (212)268-6855

The new single health insurance application, Access NY Health Care (DOH-

4220) 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

sted above.

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