New York Medicaid Forms: Official Form Numbers, What Each One Is For, and Where to Download It

Which New York Medicaid form do you need?

Start with your situation, not the form number. The table covers the forms people search for most, with the official download page for each.

If none of these fits, the state keeps a fuller list on its NYS Medicaid forms page, and HRA keeps the city’s on its health assistance page.

DOH-4220: the paper Medicaid application, and who should not use it

DOH-4220 is titled “Health Insurance for Older Adults, People With Disabilities and Certain Other Populations”, and the application pages are headed Access NY Health Care. The version on health.ny.gov on November 3, 2026 is dated 1/23.

The state Health Department is explicit about who should print it: people applying with their local department of social services who fall in the non-MAGI groups (older adults, people who are blind or disabled, people on SSI, people seeking community long-term care, and similar), or anyone applying with a spend-down. In New York City, the local department of social services is HRA.

If you are under 65 and applying on income, DOH-4220 is the wrong form. Your application belongs at NY State of Health, which does it online or by phone and screens for more programs at once. Filing DOH-4220 instead sends your case to the wrong system and slows it down. Which system is yours is covered in where to apply for Medicaid in NYC.

The form’s own instructions say to mail or return it to the local department of social services in the county where you live, and not to mail original citizenship or identity documents. Copies of other documents can be mailed with it or dropped off. DOH-4220 is available in English and in Spanish, Chinese, Haitian Creole, Italian, Korean, Russian, Yiddish, Polish, Bengali and Arabic.

Supplement A (DOH-5178A): when it is required

Supplement A is the part of the paper application that asks about resources and special circumstances, and DOH-4220 warns that an incomplete application cannot be processed and delays the decision. The supplement itself says it must be completed if anyone who is applying is:

• 65 or older
• certified blind or certified disabled, at any age
• not certified disabled but chronically ill
• institutionalized and applying for nursing home care, including hospital care equivalent to nursing home care

Sections A through E must be completed and the supplement signed. If anyone is applying for nursing home care, sections F and G are required too. If you are applying only for the Medicare Savings Program, the supplement says you do not need it.

The English version on health.ny.gov is dated 8/15. The state lists translations in Spanish, Chinese, Haitian Creole, Italian, Korean and Russian. Nursing home applications also involve a review of past transfers, which is why they are better started with an elder law attorney or legal services group than with the form alone: Medicaid long-term care.

HRA forms for New York City cases after you apply

Once your case is open with HRA, changes go on city forms. HRA lists these on its health assistance page, and all of them download from nyc.gov:

HRA takes MAP-751K and MAP-751W by fax at 917-639-0837, and its Medicaid Helpline is 1-888-692-6116. HRA posts many of these in Spanish, Chinese, Russian, Arabic, Haitian Creole, Korean, Bengali, Urdu, Polish, French, Italian, Yiddish and Albanian. A current address is what keeps renewal notices reaching you: how Medicaid renewals fail.

Other state forms worth knowing by number

A few more state forms come up in specific situations. Each is on health.ny.gov.

• DOH-4328, Medicare Savings Program application. A two-page application for help paying Medicare premiums, available in English and 16 other languages on the state’s forms page. Eligibility and the 2026 limits are on our Medicare Savings Programs page.
• DOH-4282, Family Planning Benefit Program application. For family planning coverage only.
• DOH-5298, Request for Assessment, Spousal Impoverishment. Either spouse can ask the local district to assess the couple’s countable resources once a continuous period of institutionalization starts. The state says the district may charge up to $25 if the request is not filed with a Medicaid application. In NYC, the state directs you to the HRA Medicaid Helpline, (888) 692-6116.
• DOH-5130, Alternative Format Supplement. For people who are blind or visually impaired and need notices in large print, audio, data CD or Braille. The DOH-4220 instructions add that NYC residents can call HRA’s Office of Constituent Services at 212-331-4640 for this.
• LDSS-4411, Recertification for Medical Assistance (Chronic Care). A renewal form the state lists for chronic care cases. Most people renew from the notice the state or HRA mails them, not from a downloaded form.

Form-2015: the Medicaid transportation form your doctor fills out

“Form 2015” is not an application. It is the medical justification form for Medicaid rides in New York City, and the patient does not complete it. The state’s NYC ordering guidelines (version 2017-1) say a practitioner (a physician, physician assistant, nurse practitioner, dentist, optometrist or podiatrist, and in some behavioral health cases a social worker) completes it when a patient needs a ride above mass transit: livery (car service), ambulette or non-emergency ambulance.

It is not needed if you can use the bus or subway. One form can cover one trip or many, and it should be updated when your condition changes. The guidelines say a form listing only a diagnosis, without describing why you cannot use public transit, is rejected. Providers download and submit it through Medical Answering Services. How to book the ride itself: Medicaid transportation.

The income chart PDF people look for

Searches for an “eligibility income chart NY PDF” usually land on the state’s How to Apply page, which carries a chart of monthly income and resource levels for people who are blind, disabled or 65+. On November 3, 2026 that chart was still labeled “Effective January 1, 2025”, so we do not reproduce its numbers here. The 2026 limits for working-age adults, which run on the federal poverty level, are on our Medicaid income limits for 2026 page.

The weak spot of any forms page, this one included, is version drift: states replace PDFs without changing the form number. Download the form the day you fill it out, from the official link, and check the version date printed in the corner.