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Explains how to request help, where to send proof documentation, and the core data needed in Sections A and B covering applicant contact details, household composition, pregnancy status, relationships, public coverage history, Social Security information, and citizenship/immigration documentation rules, including public charge notes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/access-ny-health-care-application-doh-4220/306764/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/access-ny-health-care-application-doh-4220/306764.png","ImageObject",442,249,{"name":42,"@type":43},"Mary Man","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can view the information submitted on this health insurance application?","Question",{"text":63,"@type":64},"Only Facilitated Enrollers and the State or local agencies and health plans that need the information to determine eligibility can see it. The person helping you cannot discuss it with anyone else except as required for supervision or agencies/health plans.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How should applicants determine which sections to complete?",{"text":68,"@type":64},"Applicants must read the booklet and complete Sections A through G and Sections I and J if applying only for children or as a pregnant woman applying alone. All other applicants must complete all sections. If you are 65+ or certified blind/disabled or institutionalized for nursing home care, you must also complete Supplement A.",{"name":70,"@type":61,"acceptedAnswer":71},"What information is required for household information in Section B?",{"text":72,"@type":64},"Section B requires details for everyone living with you, even if not applying, including names and birth city/state/country, and—if applicable—maiden names. For each person applying, it also requests the mother’s full maiden name. It includes questions about pregnancy, relationship to the person on Line 1, public health coverage history, Social Security numbers, and citizenship/immigration status where required.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},306764,1790548680,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":105,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":141},7421720224475,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","| Health Insurance APPLICATION | access\u003Cbr>NY\u003Cbr>health care | for Children, Adults and Families |\n| --- | --- | --- |\n\nINSTRUCTIONS  \nCONFIDENTIALITY STATEMENT All of the information you provide on this application will remain confidential. The only people who will see this information are the Facilitated Enrollers and the State or local agencies and health plans who need to know this information in order to determine if you (the applicant) and your household members are eligible. The person helping you with this application cannot discuss the information with anyone, except a supervisor or the State or local agencies or health plans which need this information.  \nPURPOSE OF THIS APPLICATION Complete this application if you want health insurance to cover medical expenses. 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.  \nIF YOU NEED HELP COMPLETING THIS APPLICATION DUE TOA DISABILITY, CALL YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. THEY WILL MAKE EVERY EFFORT TO PROVIDE REASONABLE ACCOMMODATIONS TO ADDRESS YOUR NEEDS.  \nPLEASE READ the entire application booklet before you begin to fill out the application. If you are applying ONLY for children or if you are a pregnant woman applying alone, you must complete only Sections A through G and Sections I andJ. Other applicants must complete all sections.  \nIf you are 65 years old or older, certified blind, certified disabled, or institutionalized and applying for coverage of nursing home care, you must also complete Supplement A. The supplement includes questions about your resources, such as money in the bank or property you own.  \nWhenever you see the words SEND PROOF on the application refer to the “Documentation Needed When You Apply for Health Insurance”section for a listing of acceptable supporting documents.  \nHOW TO GET HELP When applying for public health insurance, you DO NOT need to visit your local department of social services or a Facilitated Enroller for an interview, but you MAY come in or contact a Facilitated Enroller for help filling out this application. You can get a list of Facilitated Enrollers where you got this application, or by calling 1-800-698-4543. ALL HELP IS FREE.  \n(1-877-898-5849 TTY line for the hearing impaired)  \nSECTION A  Applicant’s Information  \nWe need to be able to contact the people applying for health insurance. The home address is where the people applying for health insurance live. The mailing address, if different, is where you want us to send health insurance cards and notices about your case. You can also tell us if you want someone else to get information about your case and/or to be able to discuss your case.  \nSECTION B  Household Information  \nPlease include information for everyone who lives with you even if they are not applying for health insurance. It is important that you list everyone who lives with you so that we can make a correct eligibility decision. Include maiden name (legal name before marriage), if this applies to the person. Also include City, State and Country of birth. If a person was born outside of the United States, just write the country of birth. We also need, for each person applying, his/her mother’s full maiden name (first and last name). This information may be used to obtain proof of the applicant’s birth date under certain circumstances.  \n􀂄 Is this person pregnant? If so, when is her baby due to be born? This information helps us determine the size of your family. A pregnant woman counts as two people.  \n􀂄 Relationship to the person on Line 1. Explain how each person is related to the person listed on Line 1 (for example, spouse, child, step-child, brother, sister, niece, nephew, etc.)  \n􀂄 Public Health Coverage. If you or anyone who lives with you is already enrolled or was previously enrolled in Medicaid, the Family Planning Ben","cbCaifQhZYHE5yqu","https://ap.wps.com/l/cbCaifQhZYHE5yqu","pdf",905360,"English","# INSTRUCTIONS\n## Confidentiality Statement\n## Purpose of This Application\n## If You Need Help Completing This Application\n## Read Before You Begin\n## Getting Help\n# SECTION A  Applicant’s Information\n## Contact and addresses\n## Consent for information access\n# SECTION B  Household Information\n## Include everyone in the household\n## Pregnancy and due date questions\n## Relationships and public health coverage\n## Social Security Number\n## Citizenship and immigration status\n# PUBLIC CHARGE INFORMATION\n## USCIS guidance and what the state will report","[{\"question\":\"Who can view the information submitted on this health insurance application?\",\"answer\":\"Only Facilitated Enrollers and the State or local agencies and health plans that need the information to determine eligibility can see it. The person helping you cannot discuss it with anyone else except as required for supervision or agencies/health plans.\"},{\"question\":\"How should applicants determine which sections to complete?\",\"answer\":\"Applicants must read the booklet and complete Sections A through G and Sections I and J if applying only for children or as a pregnant woman applying alone. All other applicants must complete all sections. If you are 65+ or certified blind/disabled or institutionalized for nursing home care, you must also complete Supplement A.\"},{\"question\":\"What information is required for household information in Section B?\",\"answer\":\"Section B requires details for everyone living with you, even if not applying, including names and birth city/state/country, and—if applicable—maiden names. For each person applying, it also requests the mother’s full maiden name. It includes questions about pregnancy, relationship to the person on Line 1, public health coverage history, Social Security numbers, and citizenship/immigration status where required.\"}]","Access NY Health Care Application - DOH-4220 | PDF",1789840847,6]