[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-306763-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-306763-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","health-insurance-application-instructions-and-confidentiality-statement","Health Insurance - Application Instructions and Confidentiality Statement","","Application instructions and confidentiality statement for a health insurance program for older adults, people with disabilities, and certain other populations. Explains how the information provided will be kept confidential, who may access it, and the purpose of the application for covering medical expenses and certain related premiums or services. Provides guidance on when and how to complete supplemental sections for specific groups, where to seek help, acceptable documents, and how to submit the completed application. Includes start of form sections for applicant and family information, with detailed prompts for contacts, relationships, pregnancy, coverage status, identifiers, citizenship/immigration, and race/ethnicity.",{"@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/health-insurance-application-instructions-and-confidentiality-statement/306763/",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/health-insurance-application-instructions-and-confidentiality-statement/306763.png","ImageObject",442,249,{"name":42,"@type":43},"Aldword","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",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can view the information you provide on this application?","Question",{"text":63,"@type":64},"All information provided will remain confidential. Only Assistors and relevant State/local agencies and health plans will see it to determine eligibility.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What is the purpose of this health insurance application?",{"text":68,"@type":64},"Complete the application to seek health insurance coverage for medical expenses, including possible use for Medicaid, the Family Planning Benefit Program, or assistance paying health insurance premiums.",{"name":70,"@type":61,"acceptedAnswer":71},"What must be completed in Sections A and B for eligibility decisions?",{"text":72,"@type":64},"Section A gathers contact and address details. Section B requires listing everyone living with you, including their relationship and details such as pregnancy status, coverage history, identifiers, citizenship/immigration status, and race/ethnicity (optional with codes).","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},306763,1790126298,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"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},2336478940917,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Health Insurance  \nfor Older Adults, People With Disabilities and Certain Other Populations  \nAPPLICATION  \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 Assistors 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 family 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 TO A 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. This application, along with Supplement A, must be filled out completely if you are 65 years old or older, certified blind, certified disabled or institutionalized, and/or if you are applying for coverage of nursing home care. Supplement A includes questions about your resources, such as money in the bank or property you own. This application is also used when applying through a provider, for individuals who are pregnant or under 19. If the application is for a pregnant person or child under 19, only Sections A thorough G, I, and J must be completed.  \nAny other Medicaid applicants must apply through NY State of Health. You can contact NY State of Health by visiting their website at [https://nystateofhealth.ny.gov/](https://nystateofhealth.ny.gov/), or by phone at 1-855-355-5777.  \nWhenever you seethe words SEND PROOF on the application refer to the “Documents Needed When You Apply for Health Insurance” section for a listing of acceptable  \nsupporting documents, pages 4-6.  \nHOW TO GET HELP When applying for public health insurance, you DO NOT need to visit your local department of social services or an Assistor for an interview, but you MAY come in or contact an Assistor for help filling out this application. You can get a list of Assistors where you got this application, or by calling 1-800-698-4543. You may also call the Medicaid help line at 1–800–541–2831. ALL HELP IS FREE.  \n(1-877-898-5849 TTY line for the hearing impaired)  \nAfter you have completed this application please mail/return to the local department of social services in the county in which you reside. [https://www.health.ny.gov/health_care/medicaid/ldss.htm](https://www.health.ny.gov/health_care/medicaid/ldss.htm)  \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/orto be able to discuss your case.  \nSECTION B  Family 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 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.  \n􀂄 Is this person pregnant? If so, when is the baby due to be born? This information helps us determine the size of your family. A pregnant pe","cbCaidEKEOuCMmDF","https://ap.wps.com/l/cbCaidEKEOuCMmDF","pdf",767475,20,"English","# Application Instructions\n## Confidentiality Statement\n## Purpose of This Application\n## If You Need Help Completing This Application\n## How to Get Help\n## Section A - Applicant’s Information\n## Section B - Family Information\n## Section C - Family Income (Money Received)","[{\"question\":\"Who can view the information you provide on this application?\",\"answer\":\"All information provided will remain confidential. Only Assistors and relevant State/local agencies and health plans will see it to determine eligibility.\"},{\"question\":\"What is the purpose of this health insurance application?\",\"answer\":\"Complete the application to seek health insurance coverage for medical expenses, including possible use for Medicaid, the Family Planning Benefit Program, or assistance paying health insurance premiums.\"},{\"question\":\"What must be completed in Sections A and B for eligibility decisions?\",\"answer\":\"Section A gathers contact and address details. Section B requires listing everyone living with you, including their relationship and details such as pregnancy status, coverage history, identifiers, citizenship/immigration status, and race/ethnicity (optional with codes).\"}]","Health Insurance - Application Instructions and Confidentiality Statement | PDF",1789840845,7]