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Department of Social Services, Finance Office, Division of Accounts Receivable and Billing

You are about to make a payment for medical coverage. Your payment will be shared with the HRA Medicaid program and coverage will be provided if your payment is equal to or greater than your surplus amount.

IF YOU ARE IN A MANAGED LONG-TERM CARE (MLTC) PROGRAM DO NOT MAKE YOUR PAYMENT HERE, PAY YOUR PROVIDER.

Client Identification # (CIN)

Last 4 digits of SSN

I am the client making a payment by a credit card in my name.

I am a third party payer and I attest that the funds used to support any and all Surplus Program payments made from my accounts on behalf of the CIN listed above were provided to me by the Client.

Additional Terms & Conditions for THIRD PARTY PAYER:

Pursuant to 18 N.Y.C.R.R. Section 360-4.8(c)(4), Medicaid coverage under the Surplus Pre-Payment Program (Pay-In) can only be authorized when payment is made using a recipient's own net available excess income. Payment must be made by the recipient, a legally responsible relative living with the recipient whose income is counted in the recipient's Medicaid budget, a legally responsible third party (guardian, power of attorney, etc.) using the recipient's own funds, or a third party who attests to the fact that they are using the recipient's funds.
If you are a third-party payer, you attest that the funds used to make this payment from your account(s) on behalf of the recipient were provided to you by the recipient for whom you are making a payment.
You certify that the statement above is true, correct, and complete with the full understanding that failing to tell the truth could result in loss of benefits for the recipient.