Get Ny Doh-3608 2018-2025

Filling out the NY DOH-3608 form is essential for determining a person's eligibility for the New York State Department of Health's Uninsured Care Programs. This guide provides step-by-step instructions on how to accurately complete the form online, ensuring a smooth submission process.

Follow the steps to successfully complete the NY DOH-3608 form.

1. Click ‘Get Form’ button to access the NY DOH-3608 document, which will open in the editor for you to complete.
2. Begin filling out the 'Patient Information' section. Enter the last name, first name, and middle initial of the patient. Provide the patient’s address, including the street address, apartment number, city, state, and ZIP code.
3. Input the patient's date of birth in the format Month/Day/Year and their Social Security number. Include both home and alternate phone numbers to ensure effective communication.
4. Move to the 'Practitioner Information and Verification' section. Enter the last name, first name, and middle initial of the attending clinician. Complete the NPI number and NYS license number fields.
5. Provide the name of the hospital or facility associated with the clinician, as well as their Medicaid number. Fill out the address details, including city, state, and ZIP code, along with the office phone.
6. Specify an alternate contact for medical follow-up by providing their name and phone number, along with an email address if available.
7. On the reverse side of the form, answer the medical eligibility questions. Ensure to include the patient's name and date of birth at the top.
8. Respond to the question about HIV status and document the date of the first positive test, if applicable. If the patient is applying under the PrEP-AP program, verify their negative HIV test result.
9. Answer questions regarding the patient's history with Hepatitis A, B, and C. Include details about any risks associated with the patient's medical history.
10. After completing the necessary fields, review all entered information for accuracy. The practitioner must certify the application by signing and dating it.
11. Once the form is thoroughly completed and reviewed, save the changes, download the document, and prepare to mail it to the provided address: Empire Station, P.O. Box 2052, Albany, New York 12220-0052.

Begin your application process by filling out the NY DOH-3608 form online today.