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If you have Medicaid and need help apply for MEDICARE the New York State Department of Health has contracted with several agencies that can help you. Contact one of our Facilitated Enrollers who can help you apply for MEDICARE .
Note: All forms are in Portable Document Format (PDF) DOH Form. Title. Also available in the following languages: DOH-4243. Medicaid Cancer Treatment Program. Español (Spanish) DOH-4282. Family Planning Benefit Program Application.
This application can be used to apply for Medicaid, the Family Planning Benefit Program, or for assistance paying your health insurance premiums. You can apply for yourself and/or immediate family members living with you.
can be used to apply for Medicaid, the Family Planning Benefit Program, or for assistance paying your health insurance premiums. You can apply for yourself and/or immediate family members living with you.
Since 2010, the New York State Department of Health Medicaid application form is called the Access NY Application or Health Insurance Application or form DOH-4220. Download the most recent version of the form at this link. (As of 02-06-24, the form was last updated in January 2023.)
If you wish to only apply for MA, you can go online at https://nystateofhealth.ny.gov/ and/or call 1-855-355- 5777 for more information or to apply, or you may use the MA-only paper application, Form DOH-4220, which your worker can give you, or call MA help line at 1-800-541-2831.
DOH 4220 - AccessNY health care Health Insurance APPLICATION for Children Adults and Families - DD (Data Disc) File DOH 4220 - AccessNY health care Health Insurance App Children Adults and Families - DD (Data Disc) 8_2021.pdf