Medicaid Member Forms

From payment authorization forms to income declaration forms and more, find complete resources for Medicaid. En Espanol.

Medicaid

• Download these helpful forms to manage your Medicaid coverage.

  • Health Survey (PDF)
  • Encuestra de Salud (PDF)
  • Declaration of Support (PDF)
  • Financial Maintenance Form (PDF)
  • Financial Status Reporting for Farm or Business (PDF)
  • Notice of Rights and Responsibilities for Support (PDF)
  • Rental Income Declaration (PDF)
  • Self-Declaration of Income (PDF)
  • Verification of Employment (PDF)

  
  

Pharmacy

• Pharmacy Forms

  • CVS Caremark Mail Service Order Form (PDF)
  • CVS Caremark Prescription Reimbursement Claim Form (PDF)

  
  

Advance Directives/Advance Care Planning – New York

• Advance Directives What You Need to Know (PDF)
• Directivas Avanzadas Lo Que Necesita Saber (PDF)
• NYSBA Living Will and Health Care Proxy Forms