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Includes sections for consent, signatures, instructions to type or print clearly, verification documents, and questions on retroactive reimbursement, other health insurance premiums, support payments, and trust beneficiary information.",{"@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/new-york-state-department-of-health-medicare-savings-program-application/306234/",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/new-york-state-department-of-health-medicare-savings-program-application/306234.png","ImageObject",442,249,{"name":42,"@type":43},"Pentious","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-07","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",6,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the Medicare Savings Program application request about the applicant and household?","Question",{"text":63,"@type":64},"It collects contact details (names, addresses, phone numbers), shelter status, and for applicant, spouse, and children under 18: date of birth, sex, optional gender identity, Social Security number, and race/ethnicity group using provided codes.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What Medicare-related fields must be completed?",{"text":68,"@type":64},"The form requests the applicant’s Medicare number and whether Medicare Part A and Part B are held, including the effective dates for each. It also collects the spouse’s Medicare number and Part A/B status with effective dates.",{"name":70,"@type":61,"acceptedAnswer":71},"What does the consent and verification section require?",{"text":72,"@type":64},"The applicant/representative acknowledges agreeing to investigations to verify information related to a Medicaid request for MSP. The instructions also require submitting verification documents such as copies of Medicare card(s), proof of income, proof of date of birth, and documentation for other health insurance premiums when applicable.","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},306234,1791146958,{"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":26,"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":22},1374404730887,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","NEW YORK STATE DEPARTMENT OF HEALTH  \nOfce of Health Insurance Programs Medicare Savings Program Application  \nPlease print clearly and do not write in the dark shaded area.  \nAPPLICANT  \n\n| First Name, Middle Initial, Last Name |  | Home Phone Number\u003Cbr>( ) |  |  |\n| --- | --- | --- | --- | --- |\n| Home Address Street Apt. No. | City | State | Zip Code | County |\n\nIs this a shelter?  Yes  No  \n\n| Mailing Address Street/P.O. Box (If Diferent from Above) Apt. No. | City | State | Zip Code | County |\n| --- | --- | --- | --- | --- |\n\nNAMES  \nList your name frst. Include aliases and maiden name. If necessary, attach an extra sheet to list all children.  \n\n| First Name, Middle Initial, Last Name | Date of Birth\u003Cbr>(MM/DD/YY) | Sex\u003Cbr>M, F, X | Gender Identity**\u003Cbr>(Optional) | Social Security Number | Race/Ethnicity Group\u003Cbr>(See codes below) |\n| --- | --- | --- | --- | --- | --- |\n| Self | / / |  |  | — — |  |\n| Spouse | / / |  |  | — — |  |\n| Child* | / / |  |  | — — |  |\n| Child* | / / |  |  | — — |  |\n\n*If under 18 years of age  \n**Gender Identity: Gender identity is how you perceive yourself and what you call yourself. Your gender identity can be the same as or diferent from your sex assigned at birth. Gender Identity Codes: M-Male, F-Female, N-Non-Binary or Non-Conforming, X-X, T-Transgender, D-Diferent Identity: Describe your Identity in space provided.  \nRace/Ethnic Group Codes: B-Black or African American, W-White, H-Hispanic or Latino, †A-Asian or Pacifc Islander, I-American Indian or Alaskan Native,  \n†P-Native Hawaiian or other Pacifc Islander, U-Unknown, O-Other.  \n†If you have selected A-Asian, or P-Native Hawaiian or Pacifc Islander please see below information on Other AAPI.  \n‡Other Asian American/Pacifc Islander (optional) -Please identify your AAPI subgroup. Subgroups within this community include, but are not limited to: Chinese, Japanese, Filipino, Korean, Vietnamese, Cambodian, Indonesian, Pakistani, Sri Lankan, Taiwanese, Native Hawaiian, Samoan, Tongan, Guamanian or Chamorro, Marshallese, Fijian, and other.  \nCITIZENSHIP INFORMATION  \nAre you a U.S. citizen?  Yes  No  \nIf No, do you have satisfactory immigration status?  Yes  No Include alien number, date of status, and date entered country, if applicable.  \n\n| Alien Number | Date of Status (DOS) | Date Entered Country (DEC) |\n| --- | --- | --- |\n\nIs your spouse a U.S. citizen?  Yes  No  \nIf No, does your spouse have satisfactory immigration status?  Yes  No Include alien number, date of status, and date entered country, if applicable.  \n\n| Alien Number | Date of Status (DOS) | Date Entered Country (DEC) |\n| --- | --- | --- |\n\nMEDICARE INFORMATION  \n\n| Applicant’s Medicare Number (From Red and Blue Medicare Card) |  |  |  |\n| --- | --- | --- | --- |\n| Do you have Medicare Part A?  Yes  No | Efective Date | Do you have Medicare Part B?  Yes  No | Efective Date |\n\n\n| Spouse’s Medicare Number (From Red and Blue Medicare Card) |  |  |  |\n| --- | --- | --- | --- |\n| Does your spouse have Medicare Part A?  Yes  No | Efective Date | Does your spouse have Medicare Part B?  Yes  No | Efective Date |\n\nWould you like us to consider providing retroactive reimbursement of your Medicare premium?  Yes  No Do you or your spouse pay any health insurance premiums other than Medicare?  Yes  No  \n\n| Who? | Monthly Amount $ |\n| --- | --- |\n\nDo you or your spouse pay child/spousal support?  Yes  No  \n\n| Who? | Monthly Amount $ |\n| --- | --- |\n\nDo you or your spouse receive payments from or are named benefciary of a trust?  Yes  No  \n\n| Who? | Value\u003Cbr>$ |\n| --- | --- |\n\nINCOME  \nList 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.  \n\n| Name of Applicant, Spouse, or Child Under 18 | Who Provides the Money?\u003Cbr>(Name/Source of Income) | What Amount? | How Ofen?\u003Cbr>(Weekly, Every Two Weeks, Monthly, Other) |\n| --- | --- | --- | --- |\n|  |  |  ","cbCaipeXWDoAF5rV","https://ap.wps.com/l/cbCaipeXWDoAF5rV","pdf",296358,"English","# Applicant\n# Names\n## Gender Identity and Race/Ethnicity Codes\n# Citizenship Information\n# Medicare Information\n# Income\n# Consent and Signatures\n# Instructions and Required Documents","[{\"question\":\"What information does the Medicare Savings Program application request about the applicant and household?\",\"answer\":\"It collects contact details (names, addresses, phone numbers), shelter status, and for applicant, spouse, and children under 18: date of birth, sex, optional gender identity, Social Security number, and race/ethnicity group using provided codes.\"},{\"question\":\"What Medicare-related fields must be completed?\",\"answer\":\"The form requests the applicant’s Medicare number and whether Medicare Part A and Part B are held, including the effective dates for each. It also collects the spouse’s Medicare number and Part A/B status with effective dates.\"},{\"question\":\"What does the consent and verification section require?\",\"answer\":\"The applicant/representative acknowledges agreeing to investigations to verify information related to a Medicaid request for MSP. The instructions also require submitting verification documents such as copies of Medicare card(s), proof of income, proof of date of birth, and documentation for other health insurance premiums when applicable.\"}]","New York State Department of Health - Medicare Savings Program Application | PDF",1789834538]