If you recieve Medicaid through your local department of social service (LDSS), you may fill out form DOH-5247 and submit this with your renewal. This application can be used to apply for Medicaid, the.Family Planning Benefit Program, or for assistance paying your health insurance premiums. You may continue to call the HRA Medicaid Helpline at 1-888-692-6116 if you have any questions about your Renewal Form. The following are required to file your petition: ! The New York State Department of Health Medicaid application form is called the Access NY Application or Health Insurance Application or form DOH-4220. A support petition is a form that tells both your husband (the respondent) and the Judge what you (the petitioner) want. Child Support Forms ; 4-9a. A New York Medicaid planning lawyer explains how you could legally refuse to pay for a spouse's long-term costs while maintaining benefit eligibility. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.