Doh 4496es 2025

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278 votes

The document is an application form for the Medicare Savings Program provided by the New York State Department of Health. It collects personal information from applicants, including their Medicare details, income sources, and health insurance premiums. The form also outlines the necessary documentation required for eligibility determination and includes terms, rights, responsibilities, and penalties related to providing false information. Additionally, it emphasizes non-discrimination in the application process.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (278 Votes)

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