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DOH 5147 - Submission

This document is a form for submitting a Medicaid application on behalf of an applicant aged 18 or older, requiring completion of specific sections and proof of authorization. It includes sections for applicant information, the person signing on behalf of the applicant, and the reason for submission, with options for authorization types. The form must be signed by the person completing it and by the applicant or their legal representative to authorize the application process.

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0% found this document useful (0 votes)
101 views2 pages

DOH 5147 - Submission

This document is a form for submitting a Medicaid application on behalf of an applicant aged 18 or older, requiring completion of specific sections and proof of authorization. It includes sections for applicant information, the person signing on behalf of the applicant, and the reason for submission, with options for authorization types. The form must be signed by the person completing it and by the applicant or their legal representative to authorize the application process.

Uploaded by

retiredtomaine
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Medicaid Enrollment and Exchange Integration Submission of Application on Behalf of Applicant

COMPLETE THIS FORM IF SOMEONE OTHER THAN


THE APPLICANT SIGNED THE MEDICAID APPLICATION

If you are signing a Medicaid application on behalf of an applicant who is age 18 or older, complete Sections A
through C and submit this form along with proof of authorization (if applicable). Failure to submit this form
and/or proof of authorization may result in a denial or discontinuance of Medicaid benefits.
The authorization in Section D may be used by the applicant to allow you to apply for Medicaid on his/her behalf.

SECTION A APPLICANT INFORMATION


Last Name First Name Middle Initial
Applicant’s Name ROSA DIAS

Social Security Number Date of Birth

SECTION B INFORMATION FOR PERSON SIGNING APPLICATION ON APPLICANT’S BEHALF


Last Name First Name
Name of Person Signing Application

Relationship to Applicant Phone


Number Street Apt. Number
Address
City State Zip Code

If a representative of a facility/company/agency is signing application, provide the following information:

Name of Facility/Company/Agency Nassau-Suffold Hospital Council, Inc


Number Street Suite Number
Address 800 Veterans Memorial Highway 150
City State Zip Code
Hauppauge NY 11788
Last Name First Name
Name of Representative

Title Medicaid & Medicare Facilitated Enroller Phone 6 3 1 4 3 5 3 0 0 0

DOH-5147 (4/15) Page 1 of 2


SECTION C REASON FOR SUBMISSION

INSTRUCTIONS: If you are signing a Medicaid application on behalf of the applicant, you must provide the
authorization/legal document authorizing you to apply on the applicant’s behalf OR attest that the applicant
is incompetent or incapacitated. Please check the appropriate boxes below. Attach the authorization
(if applicable) to this form and sign and date below.

I have authorization to apply for Medicaid on behalf of the applicant.


(Check the box for the type of authorization you have and submit
the authorization OR complete Section D below.)
Guardianship Document
Power of Attorney (POA) Document
Other Written Authorization (Specify)_________________________________________________

I attest that the applicant is incompetent or incapacitated. S/he is unable to sign the application herself/himself
and is unable to provide written consent for me to apply on his/her behalf.

Signature of Person Completing This Form _____________________________________________________


Date Signed _______________________________

SECTION D AUTHORIZATION TO APPLY FOR MEDICAID ON APPLICANT’S BEHALF

INSTRUCTIONS: If the applicant would like to provide the below authorization allowing you to represent him/her
in applying for and/or renewing Medicaid, the applicant or his/her legal representative or spouse must sign the
authorization below.
NOTE: If a legal representative is signing this authorization, also include the legal document giving him/her
authority to act on behalf of applicant.

I authorize the person or the facility/company/agency named in Section B of this form to represent me in the Medicaid
application and/or renewal process.
I authorize the release of necessary information/documentation between the local Department of Social Services/
Medicaid Program and the person or facility/company/agency named in Section B in regard to my application and/or
continuing eligibility.

Signature of Applicant/Legal Representative/Applicant’s Spouse _____________________________________


Date Signed _______________________________

DOH-5147 (4/15) Page 2 of 2

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