GIS 12 MA/006: New York Health Care Proxy Form

To: Local District Commissioners, Medicaid Directors

From: Judith Arnold, Director - Division of Health Reform and Health Insurance Exchange Integration

Subject: New York Health Care Proxy Form

Effective Date: Immediately

Contact Person: Local District Support Unit - Upstate (518) 474-8887, New York City (212) 417-4500

The purpose of this General Information System (GIS) message is to inform local departments of social services (LDSS) of a new requirement to provide the New York Health Care Proxy form (DOH publication #1430) to all interested individuals applying for Medicaid.

Chapter 512 of the Laws of 2011 requires that every person making application for Medicaid, and every person on whose behalf an application is made, if interested, be given the New York State Department of Health (DOH) model Health Care Proxy form (DOH publication #1430) by the person taking the application, except where doing so would impede the immediate provision of health care services. The provision was effective November 22, 2011.

The Medicaid application is the optimum vehicle for informing applicants of the Health Care Proxy form. Until the application can be revised to include language pertaining to how to access the Health Care Proxy form, Medicaid applicants who mail in their application will be apprised of the Health Care Proxy form via a message attached to CNS acceptance and denial notices. These notices will contain language informing the applicant of the Health Care Proxy form and supply the DOH web site address where the form may be accessed and printed. The language on the notice will also supply the New York Health Options toll-free number (1-800-541-2831) should the applicant wish to obtain a paper copy of the form. Additionally, the notice will instruct the applicant to please NOT send the completed form to the LDSS. In the event a LDSS receives a completed Health Care Proxy form from a Medicaid applicant, the LDSS worker should return the form to the applicant.

For Medicaid applicants who present at the LDSS to submit a Medicaid application or apply through a facilitated enroller, the LDSS worker or facilitated enroller, if applicable, must inform the applicant of the Health Care Proxy form and offer to assist interested individuals in obtaining a copy of the form, either by providing a copy of the form and the associated informational materials printed from the DOH web site at:


or by providing the applicant with the New York State DOH web address where