Medicaid Member Forms

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

Child Health Plus

• Download these helpful forms to manage your Child Health Plus coverage.

  • Direct Payment Authorization (PDF)
  • Documents Needed When Renewing Coverage (PDF)
  • Exception to 90 Day Waiting Period (PDF)
  • Request for Review of Child Health Plus Premium Contribution Level (PDF)

  
  

Medicaid

• Download these helpful forms to manage your Medicaid coverage.

  • 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)
• NYSBA Living Will and Health Care Proxy Forms