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MAIL TO: MEDICAID/FAMILY HEALTH PLUS (FHPlus)
Mail Renewal Program RENEWAL FORM
HRA/Medical Assistance
Program
PO Box 329060
Brooklyn, NY
11232-9823
LOCATION: 24
NOTICE DATE:
CASE NUMBER: 00021523286J
NUMBER OF ADULTS: 1
NUMBER OF CHILDREN: 0
PRIORITY: N
RVI CODE:

Carefully read the "guide booklet" that came with this form before you begin to answer any questions. To allow us to determine if
you can continue receiving Medicaid/Family Health Plus (FHPlus), you must:
1. Answer all questions on this form.
2. Look for instructions about sending proof in each section of the form. If the instructions tell you to send proof
(documentation) or the level of coverage you need requires you to send proof, see the enclosed Documentation Guide for a
list of the proofs that we accept.
3. Return this form and all needed proofs (documents) in the enclosed envelope.
If we do not receive this form and the needed proofs in our office before 05/13/2011 your Medicaid/FHPlus will end.

HOUSEHOLD:
• If someone has left the household, cross-out her/his name.
• If "Add SSN" is printed in the Social Security Number (SSN) column for any person, write-in the SSN.
° If that person does have a SSN, send the most current dated form SSA-5028 from the Social Security Administration (SSA) or a
signed letter from SSA confirming that the person applied for a SSN.
° If that person is pregnant, write "pregnant."
• If "Send Proof" is printed in the Citizenship/Immigration Status column, send the most recent letter from the United States Citizenship
and Immigration Services (USCIS) or proof of current citizenship/immigration status.
Citizenship/
Date of Sex Social Security No
Name Immigration
Birth (M/F) Number (SSN) Change
Status
01 GIANCARLOS PEREZ 03-06-1987 M Number on File []
02 []
03 []
04 []
05 []
06 []
07 []
08 []
09 []
10 []
11 []
12 []
() X Indicates additional members are on the case.

RESIDENCE AND TELEPHONE NUMBER: Is the address and telephone number printed below correct?

• If it is correct, check the "No Change" box.

• If it is not correct, write-in the most current information.
• If you need long term care services, Send Proof of your address if you are changing what is printed below.
No Change
Address:4520 BROADWAY 3F NEW YORK NY 10040 _____________________________________
[]
Phone Number: (347)235-1037 []

MAP - 2096F (English) Rev. 03/10/09 Page:1 of 4

 INCOME: Write-in income information for anyone listed in Section and anyone in the household who is a parent, step-parent, or spouse
of those listed in Section . If you need long term care services or if you may be eligible for Medicaid with a surplus (Excess Income
Program) Send Proof of income. If you are currently enrolled in or are applying for the Medicaid Buy-In for Working People with
Disabilities (MBI-WPD) program. Send Proof of employment.
Type of Name of Employer (if Amount (before How Often (weekly/bi-
Name
Income income is from employment) taxes and deductions) weekly/monthly)
$
$
$
$
If all of the following applies to you, check "Yes." Otherwise, check "No." ☐ Yes    ☐ No
. I do not get paychecks/pay stubs.
. I get paid/tips in cash.
. I cannot get a letter from my employer and I did not file a tax return last year.
If either or both of the following apply to you, check "Yes." Otherwise, check "No." ☐ Yes    ☐ No
. I have no income.
. I am supported by another person. (If you are supported by someone else, the person providing the support must
complete and sign the Declaration of Support located on Page 4 of this booklet. You must also sign that section.)
Are you currently enrolled in or are applying for the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) ☐ Yes    ☐ No
program?

IMPORTANT NOTE: You only need to complete this section if you or someone on your case is age 65 or over, certified
blind or certified disabled.
RESOURCES: Cash on hand, saving and checking accounts, certificates of deposit, real estate/real property other than your primary residence, stocks,
bonds, trust funds, ownership of a buisness, etc.
. Write in the name(s) of the person(s) with the resources that you/they have.
. If none, write "0."
. If you need long term care services, such as a home or personal care services, Send Proof of the resources that you/they have.
Type of Resource Amount

OTHER HEALTH INSURANCE: Tell us if anyone on this case has other health insurance. Send copy of front and back of health
insurance card for each person who has other health insurance, if you havenot submitted it before. Do notlist persons who only have
Medicaid, Family Health Plus, Child Health Plus or Family Planning Benefit Program coverage Send Proof of any other health care
premium expenses other than Medicare.
Does anyone on this case have a spouse or parent who can provide health insurance for them? ☐Yes ☐No
If so, provide the following:
Name of spouse or parent: _____________________________________
Address of spouse or parent: _____________________________________
Name of related household member: _____________________________________
Name of Insurer: Premium Amount (if known) How Often Paid
$

MAP - 2096F (English) Rev. 03/10/09 Page:2 of 4

 PREGNANCY AND DISABILITY: Tell us if anyone listed in Section is pregnant. (Pregnant women do not need to provide SSN or
prove immigration status.)
Is anyone on this case pregnant? If so, send statement from medical provider verifying pregnancy and expected date of delivery.
Name of pregnant woman: Expected date of delivery Send Proof

If anyone on this case is blind or disabled, do they have to pay special expenses (non-medical) in order to work? ☐Yes ☐No
If "yes", Send Proof of special expenses paid in order to work.
Name Expenses How Often

EXPENSES: Write-in how much you pay for housing/rent and for childcare/dependent care. If you need long term care services or if you
may be eligible for Medicaid with a surplus Send Proof of childcare/dependent care expenses.

Housing/Rent: $ How Often: Childcare/Dependent care: $ How Often:

HOME EQUITY: You only need to complete this section if you need long-term care services.

Do You Own or Co-Own Your Home? ☐Yes ☐No

If "Yes", is your home equity (market value of home or the portion of the home that you own less all outstanding mortgages, liens or other debts
against the home) more than $750,000? ☐Yes ☐No

LANGUAGE:

What language do you prefer to read?________________What language do you prefer to speak?_________

OTHER PEOPLE IN HOUSEHOLD: Write in the name of anyone in the household who is not on this case and tell us what their
relationship is to person(s) listed in section
Name of Person Age Name of Person in Section Relationship

I certify under penalty of perjury that everything on this application is the truth as best I know. I have also read and understand the Terms
Rights and Responsibilities.

Signature of Consumer:_________________________________ Date:___________

SIGN HERE Signature of other Adult in Household (if applicable):______________ Date:___________

Signature of Representative (if applicable):______________________ Date:___________

TO BE COMPLETED BY THE MEDICAL ASSISTANCE PROGRAM

Worker Signature Date

Supervisor Signature Date

MAP - 2096F (English) Rev. 03/10/09 Page:3 of 4

 To be completed by the person who provides support. Please complete this section so that the Medical Assistance Program
SUPPORT
can determine eligibility for Public Health Insurance.
Name: (Print)____________________________Address: _____________________________

Phone Number:______________Relationship to person you provide support: ______________

I provide the following: (Check all that apply)

☐ Sleeping accommadations ☐ Meals ☐ Monthly cash assistance $_________________

☐ Other (explain)___________________________________________________________

I have provided the support since_______ and (Check one) ☐ I will continue to do so ☐I will not continue to do so

Do you pay medical and/or hospital expenses for this person? (Check one) ☐ Yes ☐ No

SIGN HERE
Name of person providing support: _______________ Date: ___________
Consumer must read the following and sign below.

I undertand that program officials may verify all information on this form.

SIGN HERE
Signature of Consumer: ___________________ Date: ___________

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