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. These forms and instructions are available in the General Clerk's Office, Room 108, in the Nassau County.This application can be used to apply for Medicaid, the. Family Planning Benefit Program, or for assistance paying your health insurance premiums. 4 of the enclosed Guide to Complete your Medicaid Renewal Forms for assistance. This is the only Renewal Application that will be automatically sent to you. 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. 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. Filling out the forms online will take anywhere from 30-90 minutes.