NY DOH-3608 2018-2025 free printable template
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Physician Signature MUST BE ACTUAL SIGNATURE DATE ON THE BACK OF THIS FORM PLEASE PROVIDE THE INFORMATION REQUESTED. IF YOU HAVE ANY QUESTIONS ABOUT MEDICAL ELIGIBILITY PLEASE CONTACT OUR TOLL FREE HOTLINE 1-800-542-2437. WHEN COMPLETED PLEASE RETURN TO EMPIRE STATION P. O. BOX 2052 ALBANY NY 12220-0052 DOH-3608 11/08 Page 1 of 2 MEDICAL INFORMATION Please Answer All Questions Patient s Name DOB SECTION I - DISEASE STAGING Is the applicant HIV in...
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How to fill out NY DOH-3608
How to fill out NY DOH-3608
01
Obtain the NY DOH-3608 form from the New York Department of Health website or your local health department.
02
Fill out the Personal Information section with your name, address, and contact details.
03
Provide details about your health insurance coverage, including policy numbers and names of insurance providers.
04
Complete the sections asking for information on your medical condition and any required diagnoses.
05
If applicable, list any medications you are currently taking.
06
Sign and date the form to certify that the information provided is accurate.
07
Submit the completed form according to the instructions provided, either online or via mail.
Who needs NY DOH-3608?
01
Individuals applying for health coverage assistance through New York State.
02
Residents who require services covered under the public health insurance program.
03
Patients needing to document their medical condition for eligibility verification.
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What is NY DOH-3608?
NY DOH-3608 is a form used by health care providers in New York to report and collect necessary health-related data.
Who is required to file NY DOH-3608?
Health care providers and facilities that provide services to patients covered by Medicaid are required to file NY DOH-3608.
How to fill out NY DOH-3608?
To fill out NY DOH-3608, providers must complete the required sections with accurate patient information, service details, and billing codes as specified in the form instructions.
What is the purpose of NY DOH-3608?
The purpose of NY DOH-3608 is to ensure proper documentation and reporting of health care services provided to patients, thereby facilitating Medicaid reimbursement.
What information must be reported on NY DOH-3608?
The NY DOH-3608 form requires reporting of patient demographics, diagnosis, procedures, costs, and service dates, as well as provider information.
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