Blank Doh 4328 Msp Application Template

The DOH 4328 MSP Application Form is a document provided by the New York State Department of Health for individuals seeking assistance through the Medicare Savings Program. This form helps applicants provide necessary personal and financial information to determine eligibility for financial assistance with Medicare premiums. It is essential to fill out the application accurately and provide the required documents to facilitate the application process.

If you are ready to apply for the Medicare Savings Program, please fill out the form by clicking the button below.

Article Guide

The DOH 4328 MSP Application form is a crucial document for individuals seeking to enroll in the Medicare Savings Program (MSP) through the New York State Department of Health. This program is designed to assist those with limited income in paying their Medicare premiums, ultimately making healthcare more accessible. The form requires applicants to provide essential information, including personal identification details such as names and Social Security numbers, as well as citizenship status and Medicare information. Income disclosures are central to the application, where applicants must list all sources of income, ensuring that each source is accurately documented. If applicable, the form also allows for details about dependents to be included. Clear instructions guide applicants through the verification process, emphasizing the importance of documentation, such as proof of income and residency. Additionally, by signing the application, individuals consent to investigations that may verify the provided information, underscoring both the seriousness and the importance of honesty in the process. This comprehensive approach ensures that the program effectively serves those in need while adhering to state and federal regulations.

Form Sample

NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs

Medicare Savings Program Application

APPLICANT			Please print clearly and do not write in the dark shaded area.
APPLICANT

First Name, Middle Initial, Last Name					Home Phone

Home Address Street			Apt. No.	City	State	Zip Code	County

Is this a shelter?	Yes	No

Mailing Address Street/P.O. Box (If Different from Above)			Apt. No.	City	State	Zip Code	County

NAMES

List your name first. Include aliases and maiden name. If necessary, attach an extra sheet to list all children.

	Date of Birth			Race/Ethnic Group
First Name, Middle Initial, Last Name	(MM/DD/YY)	Sex	Social Security Number	(See Codes Below)

Self

Spouse

Child*

*If under 18 years of age.

Race/Ethnic Affiliation Codes: B: Black, Not of Hispanic Origin W: White, Not of Hispanic Origin H: Hispanic A: Asian or Pacific Islander I: American Indian or Alaskan Native U: Unknown O: Other

CITIZENSHIP INFORMATION

Are you a U.S. citizen?

Yes

If No, do you have satisfactory immigration status?

Yes

No Include alien number, date of status, and date entered country, if applicable.

Alien Number

Date of Status (DOS)

Date Entered Country (DEC)

Is your spouse a U.S. citizen?

Yes

If No, does your spouse have satisfactory immigration status?

Yes

No Include alien number, date of status, and date entered country, if applicable.

Alien Number

Date of Status (DOS)

Date Entered Country (DEC)

MEDICARE INFORMATION

Applicant’s Medicare Number (From Red and Blue Medicare Card)

Do you have Medicare Part A?

Yes

Effective Date

Do you have Medicare Part B?

Yes

Effective Date

Spouse’s Medicare Number (From Red and Blue Medicare Card)

Does your spouse have Medicare Part A?

Yes

No Effective Date

Does your spouse have Medicare Part B?

Yes

No Effective Date

Would you like us to consider providing retroactive reimbursement of your Medicare premium?

Yes

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

Yes

Who?

Monthly Amount

Do you or your spouse pay child/spousal support?

Yes

Who?

Monthly Amount

Do you or your spouse receive payments from or are named beneficiary of a trust?

Yes

Who?

Value

INCOME

List below all available income such as: salary, wages, pension, social security, severance pay, rental or business income, etc. If necessary, attach an extra sheet to list all sources of income.

Name of Applicant, Spouse, or Child Under 18

Who Provides the Money? (Name/Source of Income)

What Amount?

How Often?

(Weekly, Every Two Weeks, Monthly, Other)

Do you want to receive notices in:

English Only

Spanish and English

CONSENT

I understand that by signing this application/certification form I agree to any investigation made by the Department of Social Services to verify or confirm the information I have given or any other investigation made by them in connection with my request for Medicaid. If additional information is requested, I will provide it.

SIGNATURES

Applicant/Representative Signature		Date

Spouse Signature		Date


Representative Address

City			State	Zip Code

Phone Number	Relationship

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INSTRUCTIONS

COMPLETE THE APPLICATION

Be sure to answer all the questions. If you are married and living with your spouse, you must complete both the “Self” and “Spouse” questions on the application (even if the spouse is not applying for the MSP).

SIGN AND DATE THE APPLICATION

If both spouses are applying, both must sign the MSP application.

INCLUDE THE FOLLOWING VERIFICATION DOCUMENTS

Please review this list and submit the documents that you will need to provide in order for the Medicaid Program to determine if you are eligible for MSP. If you are requesting retroactive reimbursement of your Medicare premiums, you must send proof of income for the previous three-months. If there is an applying spouse, the spouse must also provide documentation.

•A photocopy of the front and back of your Medicare card.

•Proof of income: Paycheck stubs, letter from employer, income tax return, award letter for any unearned income benefit such as social security, unemployment, or veteran’s benefit, or letter from renter, boarder or tenant.

•Health insurance premiums that you pay other than Medicare: Letter from employer, premium statement, or pay stub.

•Proof of date of birth: State driver’s license, U.S. birth certificate, permanent resident card (“green card”), or NYS Benefit Identification Card.

•Proof of residence: Lease/letter/rent receipt with your home address from your landlord, driver’s license (if issued in the past 6 months), utility bill (gas, electric, phone, cable, fuel or water), government ID card with address, property tax records or mortgage statement, or postmarked envelope or postcard (cannot use if sent to a P.O. Box).

•If you are not a U.S. citizen, you must provide documents indicating your current immigration status.

Mail the application and required documentation to your local Department of Social Services (LDSS) or Human Resource Administration (HRA). To find the address in your county: http://www.health.ny.gov/health_care/medicaid/ldss.htm

TERMS, RIGHTS AND RESPONSIBILITIES

By completing and signing this form, I am applying for the Medicare Savings Program. PAYMENT OF YOUR MEDICARE PREMIUM IS A MEDICAID BENEFIT.

PENALTIES

I understand that my application may be investigated, and I agree to cooperate in such an investigation. Federal and State laws provide for penalties of fine, imprisonment or both if you do not tell the truth when you apply for Medicaid benefits or at any time when you are questioned about your eligibility, or cause someone else not to tell the truth regarding your application or your continuing eligibility.

CHANGES

I agree to immediately report any changes to the information on this application.

SOCIAL SECURITY NUMBER (SSN)

If you are applying for the Medicare Savings Program, you must report your SSN, unless you are a pregnant woman. The laws requiring this are: 18NYCRR Sections 351.2, 360-1.2, and 360-3.2(j)(3); 42USC 1320b-7. SSNs are used in many ways, both within the local social services districts and also between local social services districts and federal, state, and local agencies, both in New York and in other jurisdictions. Some uses of SSNs are: to check identity, to identify and verify earned and unearned income, to see if absent parents can get health insurance for applicants, to see if applicants can get child support and to see if applicants can get money or other help.

CERTIFICATION OF CITIZENSHIP & IMMIGRATION STATUS

I certify, under the penalty of perjury, by signing my name on this application, that I, and/or any person for whom I am signing is a U.S. citizen or national of the United States or has satisfactory immigration status. I understand that information about me will be submitted to the United States Citizenship and Immigration Services (USCIS) for verification of my immigration status, if applicable. I further understand that the use or disclosure of information about me is restricted to persons and organizations directly connected with the verification of immigration status and the administration and enforcement of the provisions of the Medicaid program.

NON-DISCRIMINATION NOTICE

This application will be considered without regard to race, color, sex, disability, religious creed, national origin, or political belief.

CERTIFICATION

In signing this application, I swear and affirm that the information I have given or will give to the Department of Social Services as a basis for Medicaid is correct. I also assign to the Department of Social Services any rights I have to pursue support from persons having legal responsibility for my support and to pursue other third-party resources. I understand that Medicaid paid on my behalf may be recovered from persons who had legal responsibility for my support at the time medical services were obtained.

If after reading and completing this form, you decide that you DO NOT want to apply for the Medicare Savings Program, please sign your name below:

I consent to withdraw my application:

Applicant Signature

Date

Signature of Person Who Obtained Eligibility Information						Date	Employed By

Date Eligibility Determined By Worker							Date Eligibility Approved By

Central/Office	Application Date		Unit ID		Worker ID		Case Type	Case No.			Reuse Ind.

Case Name			District				Registry No.		Ver.

Effective Date		MA Disp.		Denial	Withdrawal		Reason Code		Proxy	No
		MA Disp.		Denial	Withdrawal				Yes	No

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⇩ PDF

Document Specifications

Fact Name	Details
Applicant Identification	The form requires the applicant's full name, home address, and phone number for identification purposes.
Citizenship Status	Applicants must affirm their U.S. citizenship status and provide details if they are not citizens.
Medicare Information	Applicants must list their Medicare numbers and provide information on Medicare Part A and B status.
Income Reporting	Applicants are required to list all sources of income to determine eligibility for the Medicare Savings Program.
Verification Documents	Submission of specific documents, such as Medicare cards and proof of income, is essential for application processing.
Consents and Agreements	Signing the application grants the Department of Social Services permission to verify provided information.
Non-Discrimination Notice	The application is processed without regard to race, color, or other protected characteristics.
Reporting Changes	Applicants must immediately report any changes affecting their application after submission.
Applicable State Laws	This form is governed by New York State regulations including 18 NYCRR Sections 351.2, 360-1.2, and 360-3.2(j)(3).

Steps to Filling Out Doh 4328 Msp Application

Completing the Doh 4328 MSP Application form is essential for individuals seeking assistance under the Medicare Savings Program. Ensuring accuracy and completeness in this process is crucial to facilitate a smoother review of your application. You will need to carefully gather personal information, income details, and supporting documents before submitting the application to your local Department of Social Services.

Obtain the Form: Download or request the Doh 4328 MSP Application form.
Contact Information: Fill out your first name, middle initial, last name, home phone number, and address. Be sure to indicate if you live in a shelter.
Mailing Address: If different from the home address, provide your mailing address.
NAMES: List your name first along with any aliases or maiden names. Include details of all children if necessary.
Date of Birth and Race: Enter the date of birth, race, ethnic group, sex, and social security number for yourself and all family members listed.
Citizenship Information: State your citizenship status and provide necessary details if you are not a U.S. citizen.
Medicare Information: Fill in your Medicare number, and indicate whether you and your spouse have Medicare Part A and B along with their effective dates.
Health Insurance Payments: Indicate if you or your spouse pay health insurance premiums and list who they pay and the amount.
Income Section: Detail all sources of income, including salary, pensions, and other benefits.
Language Preference: Specify your language preference for notices (English only or Spanish and English).
Consent Section: Read the consent statement, then sign and date the application.
Verification Documents: Prepare and include photocopies of required documentation such as your Medicare card, proof of income, and residency.
Submit the Application: Mail the completed application form along with all documents to your local Department of Social Services or Human Resource Administration.

More About Doh 4328 Msp Application

What is the DOH 4328 MSP Application form used for?

The DOH 4328 MSP Application form is used to apply for the Medicare Savings Program (MSP) in New York State. This program helps eligible individuals pay for some or all of their Medicare premiums, which can alleviate financial strain on seniors and those with disabilities.

Who is eligible to apply for the Medicare Savings Program?

To be eligible for the MSP, applicants must be Medicare beneficiaries and meet specific income and resource limits. Both individuals and married couples can apply. If you're unsure about your eligibility, consider reaching out to local social services for guidance.

What information do I need to provide on the application?

You must provide personal details, including your name, contact information, and Social Security Number. Additionally, you'll need to list your income and assets, Medicare information, and citizenship status. Documentation to verify this information may also be required.

How do I submit the DOH 4328 MSP Application form?

Once you complete the application and gather the necessary verification documents, mail it to your local Department of Social Services (LDSS) or Human Resource Administration (HRA). You can find the appropriate address for your county on the New York State Health Department website.

What happens if I need to make changes after submitting my application?

If any changes occur regarding your income or circumstances, report them immediately. Keeping your information updated ensures you maintain your eligibility and avoid issues with your benefits.

Is there a penalty for providing false information?

Yes. Providing false information on the application can result in penalties, including fines or imprisonment. It's crucial to give accurate and truthful information during the application process and whenever your eligibility is reviewed.

Common mistakes

Inadequate Detail: Failing to provide complete information is a common mistake. Each section, such as personal details, income, and Medicare information, must be thoroughly filled out. Omitting details can lead to delays in processing.
Incorrect Signatures: Not signing or dating the application can result in rejection. Both the applicant and spouse, if applicable, must sign where indicated. A missing signature delays the application.
Using Dark Ink or Poor Readability: The instructions specify that the form should be printed clearly. Using dark or faded ink makes the writing hard to read, which can cause errors in data entry.
Inadequate Documentation: Many applicants do not include necessary verification documents. For eligibility, proof of income, identity, and citizenship must be attached. Insufficient documentation can lead to application denial.

Documents used along the form

The **DOH 4328 MSP Application Form** is a crucial document for those seeking assistance through the Medicare Savings Program in New York. However, several other forms and documents are often required to complete the application process and provide a full picture of an applicant's financial and personal situation. Below is a list of essential documents that may accompany the DOH 4328. Each plays a specific role in supporting the application.

Medicare Card Photocopy: A copy of the front and back of the applicant's Medicare card is necessary for verifying enrollment in Medicare. This document helps the Department confirm the applicant’s Medicare status.
Proof of Income: Documentation such as paycheck stubs, letters from employers, tax returns, or award letters for benefits like Social Security helps establish the financial need for assistance. This proof is essential for determining eligibility.
Health Insurance Premium Documentation: Records like premium statements or letters from employers that exhibit payments made for health insurance other than Medicare are needed to understand the full financial picture of the applicant.
Proof of Date of Birth: Acceptable forms include a state driver’s license, U.S. birth certificate, or permanent resident card. This verification is vital for establishing identity and eligibility.
Proof of Residence: Documents such as utility bills, lease agreements, or government IDs can indicate the applicant's current living situation. This documentation is necessary to assure that the applicants reside in New York State.
Immigration Status Documentation: For non-U.S. citizens, it’s crucial to provide documentation showing current immigration status. This will include alien numbers and additional details about entry into the country.
Additional Income Information: If there are other income sources like rental income or trust payments, supporting documents may need to be submitted. Full disclosure of all available income aids in a more accurate assessment of eligibility.
Application Signature: Both spouses must sign the application if married and living together. This verifies the accuracy of the application and affirms the intention to seek assistance.
Withdrawal Statement (if applicable): If the applicant decides not to proceed with their application, they should indicate this decision formally by signing a withdrawal statement.

These documents collectively provide necessary evidence for determining eligibility and ensuring smooth processing of the DOH 4328 MSP Application Form. It is critical to gather all required documentation before submission to avoid delays in the assistance process.

Similar forms

The DOH 4328 MSP Application form bears resemblance to the Social Security Administration's Application for Right to Work, known as Form I-765. Similar to the DOH 4328, this form requires personal information such as name, address, and Social Security number. Both forms also necessitate documentation to confirm identity and eligibility related to specific benefits. They aim to ensure applicants can access essential services by collecting a standard set of information needed for processing their requests.

Additionally, the Medicaid Application form shares characteristics with the DOH 4328. The Medicaid Application asks for detailed information regarding an applicant’s income, resources, and family structure, mirroring the income information collected on the Medicare Savings Program application. Both forms require documentation that verifies the information provided, ensuring that the applicant meets financial eligibility criteria for receiving benefits.

Another similar document is the Supplemental Nutrition Assistance Program (SNAP) application. The SNAP application, like the DOH 4328, gathers extensive personal and financial information. Both documents aim to gauge the applicant's eligibility for government assistance programs. The need for supporting documents demonstrates a shared process of verification necessary for effective program administration.

The Low-Income Home Energy Assistance Program (LIHEAP) application also exhibits similarities to the DOH 4328. Both forms prompt applicants to provide personal data, household composition, and financial details. By requiring comprehensive information about income and expenses, both applications aim to determine eligibility for assistance with essential living expenses, such as energy costs in the case of LIHEAP.

The Medicare Part D Extra Help application parallels the DOH 4328 in its function. This form requires applicants to disclose personal demographic information, including household income and assets. Just like the MSP application, the Extra Help application assesses whether individuals meet the financial requirements to reduce their prescription drug costs, again focusing on the concept of financial need.

Another related document is the Temporary Assistance for Needy Families (TANF) application. The TANF application seeks information about household members, income, and expenses, mirroring the need for detailed personal and financial disclosures in the DOH 4328. The objective of both applications is to determine eligibility for assistance aimed at relieving financial stress among low-income families.

The Health Insurance Marketplace application also shares structural similarities with the DOH 4328. It requires applicants to submit personal information and assess their income levels to determine eligibility for health coverage options. Both applications facilitate access to federal and state health-related benefits, highlighting the importance of providing accurate information for program enrollment and support.

The Earned Income Tax Credit (EITC) application process functions similarly, asking for significant personal and financial details to determine eligibility for the credit. Similarly to the DOH 4328, the EITC requires supporting documentation to establish the applicant's income level and family size, thereby ensuring that benefits are appropriately allocated.

The Veterans Affairs (VA) Benefits application reflects similar requirements to the DOH 4328 as well. Both forms gather comprehensive personal details and income information to assess eligibility for benefits. The VA ensures that veterans receive the necessary support by capturing data that validates their need for assistance, paralleling the approach utilized in the Medicare Savings Program.

Finally, the Child Health Plus application presents further similarities to the DOH 4328. This application requires personal information and household income details to establish eligibility for health insurance coverage for children. Both applications focus on ensuring access to essential health services, hence requiring detailed financial disclosures from the applicants to verify their eligibility for support.

Dos and Don'ts

When filling out the Doh 4328 MSP Application form, consider these important do's and don'ts:

Do print clearly and legibly.
Do answer all questions honestly and completely.
Do include your spouse’s information if you are married and living together.
Do submit all required verification documents with your application.
Do sign and date the application where required.

Don't write in the dark shaded area of the form.
Don't skip any questions, especially regarding income and citizenship status.
Don't forget to check your application for errors before submitting it.
Don't provide incomplete or outdated documentation.
Don't ignore requests for additional information after initial submission.

Misconceptions

Understanding the DOH 4328 MSP Application form is essential for those seeking assistance with Medicare premiums. However, several misconceptions can create confusion. Below are some common misunderstandings:

Everyone has to submit a Social Security Number (SSN). Not necessarily. Pregnant women can apply without providing their SSN.
You can't apply if your spouse isn't eligible. This is incorrect. Even if a spouse isn’t applying for benefits, the application still requires their information.
You need a lawyer to fill out the application. While it's beneficial to seek guidance, individuals can complete the form on their own without legal assistance.
All income sources must be reported only if they are significant. In actuality, all available income, regardless of amount, needs to be listed to ensure an accurate eligibility assessment.
Verification documents are only necessary for the applicant. Both the applicant and spouse (if applicable) must provide necessary documentation to support the application.
All Medicare premium payments can be reimbursed retroactively. Reimbursement requests are only considered if the applicant explicitly indicates this on the form.
Minor children’s information is optional. In fact, if children are included in the application, their details must be listed, making them an essential part of the form.

By clarifying these misconceptions, applicants can approach the DOH 4328 MSP Application with confidence and ensure they provide all necessary information for a successful application process.

Key takeaways

Applying for the Medicare Savings Program using the DOH 4328 MSP Application form can be a vital step in managing healthcare costs. Here are four key takeaways to keep in mind when filling out and using the application:

Complete all sections carefully. Ensure that you answer every question and provide thorough information. If married, it’s essential to include both self and spouse details even if your spouse is not applying.
Documentation matters. Be prepared to submit important paperwork alongside your application. This includes proof of income, Medicare cards, and evidence of residency. Missing documents can delay the processing of your application.
Understand your consent. By signing the application, you agree to allow the Department of Social Services to verify the information you provided. Be sure to read and understand what this consent entails.
Report any changes promptly. If anything about your situation changes after you submit your application, report these changes immediately. This is crucial for maintaining your eligibility for the Medicare Savings Program.