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The form instructs applicants to read all directions first, print clearly, and submit complete information to avoid delays. It requests legal names, contact details, language spoken, address, and detailed household member data including date of birth, insurance eligibility, pregnancy status, relationship, citizenship or immigration status, race/ethnic group codes, and required proof references.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/access-ny-health-care-medicaid-family-health-plus-child-health-plus-application-form/306765/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/access-ny-health-care-medicaid-family-health-plus-child-health-plus-application-form/306765.png","ImageObject",442,249,{"name":88,"@type":89},"Ben ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does Section A collect?","Question",{"text":108,"@type":109},"Section A collects the applicant’s identity and contact information, including legal name, phone numbers, address, zip code, and what language the applicant speaks.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What must be listed in Section B for household members?",{"text":113,"@type":109},"Section B requires full legal names and benefit card ID numbers for persons applying for or already receiving Medicaid, Family Health Plus, or Child Health Plus, plus details such as date of birth, insurance application status, pregnancy status, relationship, and citizenship or immigration status.",{"name":115,"@type":106,"acceptedAnswer":116},"Which proof documents are referenced in the form?",{"text":117,"@type":109},"The form references the “Documents Needed When You Apply for Health Insurance” and a “Documentation Checklist for Health Insurance” to prove identity, citizenship, or immigration status.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306765,1790511084,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},2336478951081,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","ACCESS NY HEALTH CARE Medicaid / Family Health Plus / Child Health Plus  \n PLEASE READ the entire application and INSTRUCTIONS before you fill it out. Print clearly in blue or black ink. An incomplete application cannot be processed and will result in a delay of a decision on your application.   Section A  Applicant’s Information Please tell us who you are and how to contact you.  \nLegal First Name Middle Initial Legal Last Name  \nPrimary Phone \\# Another Phone \\#  \nHome Cell Work Other Home Cell Work Other  \nStreet  \nCity  \nStreet  \nCity  \nName  \nStreet  \nCity  \nState  \nApt.\\#  \nWhat Language Do You Speak?  \nApt.\\#  \nZip Code  \nApt.\\#  \nState  \nState  \nZip Code  \nPhone \\#  \nRead?  \nCounty  \nZip Code  \nHome Cell Work Other  \nSection B  \nHousehold Information If you live in the household, start with yourself. If you do not, start with any adults who live in the household. List the full legal names of the persons applying for or already receiving Medicaid, Family Health Plus or Child Health Plus and list the ID Number from their Benefit Card or health plan ID card. You must provide information for household members including: parents, step-parents, and spouses. You may provide information for other household members (for example, a dependent child under the age of 21).  \nListing other household members may allow us to give you a higher eligibility level. Pregnant women and children under 19 may be eligible for health insurance regardless of immigration status.  \n\n|  | Legal First, Middle, Last Name | Date of Birth\u003Cbr>\u003Cbr>SEND PROOF | Is this\u003Cbr>person\u003Cbr>applying\u003Cbr>for health\u003Cbr>insurance? | Is this person pregnant?\u003Cbr>\u003Cbr>SEND PROOF | Is this\u003Cbr>person the\u003Cbr>parent of\u003Cbr>an applying\u003Cbr>child? | What is the\u003Cbr>relationship\u003Cbr>to the\u003Cbr>person\u003Cbr>in Box 1? | If this person has or had public health coverage in the past, check the box that applies. | Social\u003Cbr>Security\u003Cbr>Number\u003Cbr>(if you\u003Cbr>have one) | Please mark one box that indicates your current Citizenship or Immigration Status.\u003Cbr>Not needed for pregnant women\u003Cbr>\u003Cbr>SEND PROOF | *Race/\u003Cbr>Ethnic\u003Cbr>Group |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 01 | Full Maiden Name (person’s birth name before they were married) City of Birth State of Birth Country of Birth\u003Cbr>This Person’s Mother’s Full Maiden Name | / / |  Yes\u003Cbr> No |  Yes\u003Cbr> No\u003Cbr>What is the\u003Cbr>Due Date?\u003Cbr>/ / |  Yes\u003Cbr> No | SELF |  Child Health Plus\u003Cbr> Medicaid\u003Cbr> Family Health Plus ID Number from Benefit Card/Plan Card, if known: |  |  U.S. Citizen\u003Cbr> Immigrant/non-citizen Enter the date you received your immigration status   /  /  Month Day Year\u003Cbr> Non-immigrant (Visa holder)\u003Cbr> None of the above |  |\n|  |  |  Male\u003Cbr> Female |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n| 02 | Full Maiden Name (person’s birth name before they were married) City of Birth State of Birth Country of Birth\u003Cbr>This Person’s Mother’s Full Maiden Name | / / |  Yes\u003Cbr> No |  Yes\u003Cbr> No\u003Cbr>What is the\u003Cbr>Due Date?\u003Cbr>/ / |  Yes\u003Cbr> No |  |  Child Health Plus\u003Cbr> Medicaid\u003Cbr> Family Health Plus ID Number from Benefit Card/Plan Card, if known: |  |  U.S. Citizen\u003Cbr> Immigrant/non-citizen Enter the date you received your immigration status   /  /  Month Day Year\u003Cbr> Non-immigrant (Visa holder)\u003Cbr> None of the above |  |\n|  |  |  Male\u003Cbr> Female |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n\nEffective 7/1/10, citizen children who provide a SSN are not required to provide identity or citizenship documentation if eligible for Child Health Plus.  \n SEND PROOF  Refer to the “Documents Needed When You Apply for Health Insurance” in the instructions on pages 1-3,“Documentation Checklist for Health Insurance”, for a list of documents that prove Identity, Citizenship or Immigration Status.  \n*Race/Ethnic Group Codes (optional): A-Asian, B-Black or African-American, I-Native American or Alaskan Native, P-Native Hawaiian or other Pacific Islander, W-White, U-Unknown. Please also tell ","cbCaim4XXiJk0vKv","https://ap.wps.com/l/cbCaim4XXiJk0vKv","pdf",255452,9,"English","# Section A: Applicant’s Information\n# Section B: Household Information","[{\"question\":\"What information does Section A collect?\",\"answer\":\"Section A collects the applicant’s identity and contact information, including legal name, phone numbers, address, zip code, and what language the applicant speaks.\"},{\"question\":\"What must be listed in Section B for household members?\",\"answer\":\"Section B requires full legal names and benefit card ID numbers for persons applying for or already receiving Medicaid, Family Health Plus, or Child Health Plus, plus details such as date of birth, insurance application status, pregnancy status, relationship, and citizenship or immigration status.\"},{\"question\":\"Which proof documents are referenced in the form?\",\"answer\":\"The form references the “Documents Needed When You Apply for Health Insurance” and a “Documentation Checklist for Health Insurance” to prove identity, citizenship, or immigration status.\"}]","ACCESS NY HEALTH CARE Medicaid - Family Health Plus - Child Health Plus - Application Form | PDF",1789840848]