Health Declaration Form New York

Complete the information below only if you have no other way to document your income.

Health declaration form new york. The new york state health form is required starting today july 14 2020 from all air passenger arrivals arriving in new york state from states with high numbers of covid 19 cases. One form per person family required in response to increased rates of covid 19 transmission in certain states within the united states and to protect new york s successful containment of covid 19 the state has issued a travel advisory for anyone entering new york from a state that. Travelers heading to new york city who are coming from a state on new york s quarantine list will be required to fill out a health declaration form ahead of check in.

Due to the closure of the office if you mailed or faxed forms or correspondence march 11 2020 or after we cannot access or process that form. New york state department of health office of health insurance programs self declaration of income. Currently the new york and tri state 14 day quarantine applies to visitors from 22 states and the list is updated weekly.

Failure to complete this form may result in denial of your application. Health insurance and nutrition application for children adults and families medicaid child health plus family health plus and family planning benefit program pdf healthy new york program hiv uninsured care programs. I get paid in cash.

This form provides details about the locations you resided in the last 14 days and if you have stopped along the way. Welcome to new york state new york state traveler health form. New york state department of he alth office of health insurance p rograms self declaration of income complete the information belo w only if y ou hav e no ot her w ay to document y our income.