Get Ny Map-2161 2013-2025

The NY MAP-2161 form is an essential document for applicants or recipients who are living with a legally responsible relative who has refused to provide income or resources for medical care. Filling out this form accurately is crucial for ensuring proper support and assistance from Medicaid. This guide will assist you in completing the form online with step-by-step instructions.

Follow the steps to complete the NY MAP-2161 online

1. Press the ‘Get Form’ button to obtain the form and display it in your editor.
2. Begin by entering the date at the top of the form.
3. Fill in your case name and case number in the designated fields.
4. Provide your printed name in the space provided for the applicant or recipient.
5. In the declaration section, indicate the relationship of the legally responsible relative (e.g., spouse, parent, or other). Clearly specify if the relationship is not listed.
6. Enter the name of the legally responsible relative, including their first and last names.
7. Provide the Social Security number of the legally responsible relative.
8. If applicable, include the name of the legally responsible relative’s health care plan and type of health care coverage.
9. Enter the policy number and contact number for the health care coverage.
10. Sign the form as the applicant or recipient and enter the date of signature.
11. Ensure that the worker's name, supervisor's name, and title are filled in as required.
12. Review all entries for accuracy before saving the completed form.
13. Once satisfied, save the changes, download or print the form for your records, and share it as necessary.

Complete your documents online today to ensure your assistance and support are processed efficiently.