Contact Information:
Does the patient live in New York?*
Yes
No
Are you the patient?*
Yes
No
Does the patient have Medicaid?*
(Medicare is
NOT
enough)
Yes
No
I don't know
The patient needs Medicaid to join. (Medicare is NOT enough).
You need Medicaid to join. (Medicare is NOT enough).
Would you like help applying or determining eligibility?*
Yes
No
Patient will need Medicaid in order to join the program.
Unfortunately, this program is only for New York residents.
**Marked fields are required fields. We always respect your privacy.
Thank you! Your submission has been received!
There was a problem submitting your request. Please call us at 718.989.1009.