New York State Medicaid Application Forms

Information derived from the New York State Department of Health (2017)


Supplement A

There are two Supplements: DOH-4495A and DOH-5178A. Please read the instructions below to see which Supplement you should use.

If you reside in a county outside of New York City, use Supplement DOH-5178A.

If you reside in the five boroughs of New York City, use Supplement DOH-4495A.

Need Assistance with Your New York Medicaid Application?

P&P Medicaid will handle the entire application & document-acquiring processes and will appear on your behalf at all interviews with the Department of Social Services (Medicaid). We will utilize our knowledge and our associations to have your application approved in a timely fashion.

Medicaid is a federally funded program run by the state and the county, which provides medical insurance and long-term care for middle-to low-income persons, including the elderly and disabled. If one is eligible, based on income and resource restrictions, Medicaid will pay for all medical care (including doctors and hospitals), prescriptions, home care, nursing home care and other healthcare-related expenses. The program differs from Medicare which is available to anyone over the age of 65 or to the certified disabled who have worked and paid into the Social Security system. Medicaid is based on income and resource levels, and although anyone can apply, eligibility needs to be approved via the application process.

Our Long Island, New York company works with our clients in Nassau County, Suffolk County and Queens in preparing applications for Medicaid eligibility, while taking advantage of programs and planning options to protect a person’s or family’s income and assets. For more information about the Medicaid application process or any of our other services or to schedule a consultation, contact our Long Island Medicaid application professionals at (516) 541-4770 or fill out our contact form.