GIS 11 MA/022: Revised Notice of Decision on your Medicaid Application, OHIP-0053 (formerly DOH-4290)
To: Local District Commissioners, Medicaid Directors
From: Judith Arnold, Director, Division of Coverage and Enrollment
Subject: Revised Notice of Decision on your Medicaid Application, OHIP-0053 (formerly DOH-4290)
Effective Date: Immediately
Contact Person: Local District Support Unit: Upstate (518)474-8887, NYC (212)417-4500
The purpose of this General Information System (GIS) message is to advise local departments of social services (LDSS) of revisions made to the DOH-4290, "Notice of Decision on your Medical Assistance Application." The Department form number of this document has been changed from DOH-4290 to OHIP-0053 (06/11). The DOH-4290 will be removed from the electronic Library of Official Documents (http://health.state.nyenet/revldssforms.htm) and will be replaced with the OHIP-0053.
The attached eligibility notice was revised to be consistent with existing policy and make it easier to read and understand.
Districts are reminded that this notice must be reproduced as a legal size document and as a two-sided (not two-page) notice both in English and Spanish. It is particularly important that this notice be two-sided to ensure that the applicant is properly identified when the notice is received by the Office of Temporary and Disability Assistance for fair hearing purposes.
