Important Forms

Hudson Health Plan understands that applying for health coverage has a lot of steps, and we’re here to help. To start the enrollment process online, click here.

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Below are links to some forms you may be asked to complete and submit to Hudson during the eligibility and enrollment process or the recertification process. Just click on each form's link in the right column to download the .PDF file and print out the form. If you have questions about any of these forms, you can always call our Customer Care Department at 1.800.339.4557.

NOTE: The printed forms must be clear and legible. Forms that are blurred or unreadable cannot be accepted. Be sure to print your form in black ink on 8 1/2-inch by 11-inch white paper. Be sure to fill out the form completely using black ink, and be sure it is signed and dated. 

FORM NAME
 NUMBER DESCRIPTION DOWNLOAD PDF
Child Health Plus Health Insurance Renewal Form HHP0032 Need to recertify? Use this form if it is time to renew for Child Health Plus and you have lost the form Hudson mailed you. English
Spanish
Declaration of Child Care Cost HHP0069 Use this form to document your child care costs. Ask the person who provides child care to complete it. English
Declaration of Child Support HHP0068 Use this form if any of your children receive child support. Ask the parent paying the child support to complete it. English
Declaration of Support HHP0060 Use this form if you receive financial or other assistance from another person. Ask the person providing the support to complete it. English
Spanish
Documentation Checklist HHP0024 This is a list of all documents necessary for enrollment. English
Spanish
Exception to Six Month Waiting Period HHP0070 Use this form if you are applying for Child Health Plus and your child has recently lost other health insurance.  This form will help us to see if you may have to wait six months before your Child Health Plus coverage begins. English
Spanish
Fax Cover Sheet N/A Use this form when faxing documents to Hudson Health Plan. English
Financial Maintenance Form HHP0058 Use this form to tell us more about how you meet your financial obligations.  Hudson may require you to complete this form during the application process, if certain conditions apply. English
Spanish
Financial Status Reporting for Farm or Business HHP0085 Use this form to tell us about your income from a business or farm, if your income has changed since your most recently filed taxes. English
Spanish
LDSS Form 4279 - Absent Parent Responsibilities and Rights LDSS4279 Use this form to learn about an applicant’s rights and responsibilities when a parent does not live with the family. English
Spanish
Request for Information About Employer Sponsored Health Insurance HHP0091 Use this form if you are eligible for Family Health Plus and need to provide information about the coverage offered by your employer. Ask your employer to complete the form. English
Request for Review of Child Health Plus Premium Contribution Level HHP0025 Use this form if your child is enrolled in Child Health Plus and your income has changed. English
Spanish
Self Declaration of Income HHP0040 Use this form only if there is no other possible way to document your income. English
Spanish
Social Security Number—Deferred Action for Childhood Arrivals N/A If the U.S. Citizenship and Immigration Services (USCIS) grants you Deferred Action status and employment authorization, you may be eligible for a Social Security number. Read this flyer for more information. English and Spanish
Verification of Employment HHP0035 Use this form if you cannot provide paystubs from the last 30 days. Ask your employer to complete this form. English
Spanish
What You Should Know Before Joining a Managed Care Health Insurance Plan HHP0052 Use this form for information you should know about joining a health plan, and the choices you have. English and Spanish
Access NY Application N/A The official Access NY Application form is for public health insurance programs in New York State. If you have not already spoken with a Hudson Health Plan representative, and you would like to begin the application process online, visit our Enroll Now! page, or contact our Customer Care Department at 1.800.339.4557. English
Spanish