Doh 2794-2026

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  1. Click ‘Get Form’ to open the doh 2794 application in the editor.
  2. Begin by filling out Section A, 'Applicant Information.' Enter your full name, social security number, and date of birth. Ensure you provide a valid address as proof of New York State residency.
  3. In Section B, 'Living Arrangement,' list all household members. Indicate their relationship to you and whether they live with you.
  4. Proceed to Section C, 'Income.' Check all applicable income sources for yourself and household members. Provide gross amounts and frequency of income received.
  5. In Section D, 'Liquid Assets,' check all applicable asset sources and indicate their current balance or value. Remember to include proof of these assets.
  6. Complete Section E regarding any health coverage you may have. Attach copies of your health insurance cards if applicable.
  7. Finally, in Section F, provide alternate contact information if necessary and sign the certification statement at the bottom before submitting your application.

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In the State of New York, to be eligible for ADAP enrollment, an individual must meet the following criteria: Have a positive /AIDS diagnosis; Be a resident of York; Financial eligibility is based on 500% of the Federal Poverty Level (FPL). FPL varies based on household size and is updated annually.
Your Insurance plan will send you an ID card with your policy ID number that is different than your Medicaid #. States that have not converted their Medicaid to MCOs usually issue a Medicaid card with a control number. For HIPPA privacy and to reduce fraud, having your full Medicaid # on an ID card is not good.
The ID number is what everyone (medical providers) and the insurance company will want. Its equivalent to policy number.
Beyond long-term care, Medicaid provides other benefits not usually covered by health insurance including non-emergency medical transportation, which helps enrollees get to appointments, and comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services.
0:23 2:56 Application specific to your provider. Type this application is usually available on the statesMoreApplication specific to your provider. Type this application is usually available on the states Medicaid. Website such as the New York State Department of Health. Website.

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