Doh form 2022-2025

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4.8 out of 5

102 votes

The document is an application form for the Family Planning Benefit Program (FPBP) provided by the New York State Department of Health. It collects personal, household, income, citizenship, and health insurance information from applicants to determine eligibility for family planning services. The form includes sections for applicant details, household members, income sources, citizenship status, and health insurance coverage. It also outlines terms, rights, responsibilities, and confidentiality agreements related to the application process.

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Begin with SECTION A: APPLICANT INFORMATION. Fill in your full legal name, home address, primary language, and phone number. If confidentiality is a concern, provide an alternative mailing address or check the box for 'No confidential address needed'.
Move to SECTION B: HOUSEHOLD INFORMATION. List your family members living with you, including their relationship to you and relevant details like date of birth and sex.
In SECTION C: INCOME, detail all sources of income and their amounts. Indicate how often you receive this income. If applicable, explain how you meet your needs if you have no income.
Proceed to SECTION D: CITIZENSHIP. Confirm your citizenship status and provide any necessary details if you are not a U.S. citizen.
Complete SECTION E: HEALTH INSURANCE by indicating any existing health coverage and answering related questions about billing concerns.
Finally, review the TERMS, RIGHTS, AND RESPONSIBILITIES section before signing the application to confirm your understanding and agreement.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (102 Votes)
2009	4.3 Satisfied (48 Votes)

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What is the doh form?

NY DOH-4359 is a report form used by healthcare providers in New York State to document and report various health-related data to the New York State Department of Health.

What does DOH mean in healthcare?

The primary function of the Department is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services.

What is the meaning of DOH application?

DOH-5088 (12/14) Verifying Your Identity. We can verify your identity by reviewing your documents. NY State of Health needs to verify your identity to finish processing your application and to give you access to your online account. You need to complete the form below and submit copies of the necessary documents.