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Who needs a DOH form 4495a?

This is an application designed by the Department of Health for residents of New York State who need Medicaid coverage for treatment or community-based long-term services, including nursing home care. One should not file this form if one is applying for the Medical Savings Program. It is a supplement for applicants who are 65 or older, certified blind or disabled, chronically ill or institutionalized.

What is form 4495a for?

This is a form for Medicaid financial benefits. Besides treatment coverage, this form is filed to seek at least partial payments for community-based services such as adult day health care, limited licensed home care, private duty nursing, hospice in the community or residence program, and other personal care services.

Is it accompanied by other forms?

Form 4495a is a supplement itself to form 4220 - a general application for health care benefits.

When is form 4495a due?

Once you filed this form with the local DOH office, you have to wait approximately 60 days for your application to be processed.

How do I fill out a DOH form 4495a?

This is in essence a financial statement for the DOH administration to decide on the amount of coverage according to an applicant’s needs. So, after you’ve given general information about yourself or about a person you’re helping apply, the list of personal assets should be made. It should contain data from the applicant’s savings, retirement, credit union account, information about life insurance policies, stocks, bonds,vehicles, equity value in home, rental property, and burial assets. The last two of six pages in this form should be completed only if it’s an application for coverage of nursing home care.

Where do I send it?

Send it to the closest department of social services electronically or via mail. You can find the list of addresses at the official website of New York State Office of Health Insurance Programs.