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Get Ny Doh-5153 2016-2025

Disability ID Number: State Disability Review Unit OCP-826 State of New York Department of Health Albany, NY 12237 Sex: Male Female Worker Name: Phone Number: 1-866-330-0591 Date: An application for benefits based on disability status has been filed on behalf of the above-named child. The information you provide below will be helpful in deciding if the child will receive Medicaid based on disability. Please leave blank any item for which you do not have information or that would not app.

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