New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENT
Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage
Part 9610 - Application And Determination Of Eligibility
Section 9610.2 - Use of the application form

Universal Citation: 9 NY Comp Codes Rules and Regs ยง 9610.2

Current through Register Vol. 46, No. 12, March 20, 2024

(a) The State-approved form must be completed:

(1) for each applicant upon initial application and recertification;

(2) when there is a change in status affecting eligibility; and

(3) in the event of a reapplication more than 30 days following the end of any eligibility period.

(b) Signatures on State-approved forms are required, as follows:

(1) For married applicants, both the husband and wife shall sign.

(2) Where the case involves a single individual, such individual shall sign.

(3) In any case where the applicant or spouse, whose signature is required, is incapable of signing the application because of physical incapability, mental incompetency or not residing in the household, the application shall be signed on behalf of such person by his authorized representative.

(c) The State-approved form shall contain the following information in addition to any other information which the contractor may require for the proper administration of the program:

(1) full name(s) of the applicant(s);

(2) date(s) of birth of the applicant(s);

(3) income amount and source(s) of the applicant(s);

(4) permanent address of the applicant(s);

(5) marital status of the applicant(s) and spouse's full name;

(6) county of residence of the applicant(s);

(7) other public or private insurance coverage(s), including medical assistance; and

(8) legal status of New York State residency.

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