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DENIAL REASON CODE WITHDRAWAL - New York State …

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 1 CENTER/ OFFICE APPLICATION DATE UNIT ID WORKER ID CASE TYPE SERV. IND CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP SUFFIX CATEGORY LANG NUMBER REUSE INDICATOR CASE NAME EFFECTIVE DATE DISPOSITION SERVICES TRANSACTION TYPE NEW OPENING REOPEN RECERTIFICATION DENIAL REASON CODE WITHDRAWAL ELIGIBILITY DETERMINED BY (WORKER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION DATE form _____ 0F _____ x DATE RECEIVED BY AGENCY EMPLOYED BY: SOCIAL SERVICES DISTRICT PROVIDER AGENCY SPECIFY: PA AUTHORIZATION PERIOD MA AUTHORIZATION PERIOD SNAP AUTHORIZATION PERIOD SERVICES AUTHORIZATION PERIOD FROM TO FROM TO FROM TO FROM TO NEW YORK State APPLICATION FOR CERTAIN BENEFITS AND SERVICES If you are blind or seriously visually impaired and need this application in an alternative format, you may request one from your social services district.

worker can give you or call MA help line at 1, 800- -541-2831. If you want to apply only for the Medicare Savings Program (MSP), you must apply with Form DOH-4328, which you rworker can provide to you. If you have an immediate need for personal care services, you should apply for MA separately using the DOH- 4220 MA application form.

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