Since  2010, the New York State Department of Health has used a uniform 6-page application form to be used for Medicaid — called the  Access NY Application or form DOH-4220.  Download the form at this link – scroll down to Application for Non-MAGI.   As of October 2016, the form was last updated in March 2015. 

As of January 1, 2014, the DOH-4220 application should not be used for Medicaid applicants in the MAGI category.  All MAGI applicants should go through the NYS Health Benefits Exchange to apply for Medicaid.

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled)   (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program fr Working People with Disabilities. 

The DOH-4220 – Access NY Health Care  application can be used for  all Medicaid benefits — including for those who want to apply for coverage of …
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New Application Form (2010, updated 3/2015) Used for Medicaid, Child Health Plus and Family Health Plus in New York State