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Planned parenthood DocHub 2025

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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 and household information, including contact details, income sources, citizenship status, and health insurance coverage. The form outlines the rights and responsibilities of applicants, confidentiality assurances, and requirements for documentation to determine eligibility for family planning benefits.

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Click ‘Get Form’ to open the Family Planning Benefit Program Application in our editor.
Begin with SECTION A: CONTACT INFORMATION. Clearly print your first name, middle initial, last name, and primary language spoken. Fill in your home address, including street, apartment number, city, state, zip code, and county.
In SECTION B: HOUSEHOLD INFORMATION, list the names of individuals living with you who are applying for FPBP. Ensure to include your spouse even if they are not applying.
Proceed to SECTION C: HOUSEHOLD INCOME. Indicate types of income received by anyone listed in Section B. Specify the amount and frequency of income.
Complete SECTION D: CITIZENSHIP by answering whether everyone applying is a U.S. citizen or national. If not, provide necessary details for non-citizens.
Review and sign the TERMS, RIGHTS AND RESPONSIBILITIES section to confirm your understanding and agreement before submitting the application.

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Planned parenthood DocHub 2025

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