Medicaid Sponsorship Application
Name *
Your answer
Date of Application *
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Date of Birth
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Estimated Due Date *
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Are you currently on NYS medicaid? If so which managed care plan? *
Your answer
Did you qualify for medicaid before you were pregnant? *
Please tell us about your birthing history, if any, including vaginal or cesarean delivery and any complications. *
Your answer
Do you self-identify as a woman of color, LGBTQ, immigrant or refugee, or a person with cognitive or physical disabilities? *
Required
What draws you to desiring an out of hospital birth? *
Your answer
Do you have partner/family/friend support for this choice? If so, please describe. *
Your answer
Do you know what a doula is? Have you considered hiring a doula? *
Your answer
Please explain why you are requesting waiver of balance billing? *
Your answer
After reviewing the recommended sliding scale on the website what if any amount do you think you would be able to contribute to the balance bill for you care? *
Your answer
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