Alternative Format Forms

If you are blind or visually impaired — you have choices on how you receive information.

You can choose to download the forms listed below or you can contact your local department of social services to request the forms listed below. Forms are available in the following formats;

  • Audio Disc (AD) – an audio transcription of the form;
  • Data Disc (DD) – a screen reader accessible form; and
  • Large Print (LP); and
  • Braille (BR). (Not available online – to order please write or call your local department of social services)

To order alternative format applications please write or call your local department of social services.

Application for Non-MAGI Individuals

The following application may only be completed if you are applying at a local department of social services (LDSS) for Medicaid because you are over the age of 65 or an individual in your household is deemed certified blind or disabled or you are applying for Medicaid with a spenddown.

You may be required to apply for Medicare as a condition of eligibility for Medicaid. Please read OHIP-0112 below for more information on who is required to apply for Medicare and how to apply.

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.

Application for the Medicare Savings Program

The following application may be used if you are applying for the Medicare Savings Program only. This program pays your Medicare premiums and deductibles.

Application for the Family Planning Benefit Program

The following application may be used if you are applying for the Family Planning Benefit Program only.

Family Planning Benefit Program Application Instructions

Family Planning Benefit Program Document Checklist

Family Planning Benefit Program Fact Sheet

Recertification for Medical Assistance (Chronic Care)

The following form should be completed by individuals who are in receipt of nursing facility services (residential health care facilities, residential treatment facilities or intermediate care facilities for the developmentally disabled). The form should be returned to your Local District Social Services Offices.

Information Concerning Medical Assistance of SSI/SSP Beneficiaries

The following form should be completed by individuals who have become eligible for Medicaid benefits because they are in receipt of Supplemental Security Income and/or State Supplement Program benefits. The form should be returned to your Local District Social Services Offices.