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Title: Section 43-2.4 - Use of the application form

Effective Date


43-2.4 Use of the application form.

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

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

(2) documentation may be required when there is a change in status affecting eligibility.

(b) The signature of the individual applying for assistance is required on the State-approved application form. In any case where the applicant is incapable of signing the application because of physical incapability, or mental incompetency, application shall be signed on behalf of such a person by his/her authorized representative.

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

(1) name, gender, date of birth, social security number, marital status, address and telephone number of the applicant;

(2) name and relationship to applicant for applicant's household members;

(3) income information for the applicant and members of the applicant's household; and

(4) information regarding any other health benefits or insurance coverage that is available to the applicant.

Statutory Authority

Public Health Law, Sections 201(1)(o), 201(1)(p) and 2776(1)(e)


VOLUME A-1 (Title 10)