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Verifying Your Identity

We can verify your identity by reviewing your documents

NY State of Health needs to verify your identity to finish processing your application and to give you access to your online account. You need to complete the form below and submit copies of the necessary documents. Please do not send originals. Once we verify your identity, we can finish processing your application and you can gain access to your online account.
If you submit a copy of a document from List A, it must have your photograph or a physical description of you, including information such as your name, age, sex, race, height, weight, and eye color. If you do not have a document from List A, you can send copies of two documents from List B. The information on both documents from List B must match.
If you are 18 years old or younger and do not have one document from List A or two documents from List B, then you may submit one copy of a document from List C.
Once you have completely filled out the form and collected copies of the documents listed below, you can:
Mail them to: NY State of Health, PO BOX 11727, Albany, NY 12211 OR
Fax them to: NY State of Health at 1-855-900-5557.
NEED HELP WITH THIS FORM? Call us at 1-855-355-5777. TTY users should call 1-800-662-1220 or 1-877- 662-4886 for TTY in Spanish.

Identity Verification Form

Applicant Name
Address

List A

Submit a copy of ONE

  • U.S. Passport book or card
  • Foreign Passport book or card
  • Driver’s license
  • Official Government Identification card
  • School Identification card
  • U.S. military card or draft record
  • Military dependent’s Identification card
  • Native American Tribal Document
  • U.S. Coast Guard Merchant Mariner card
  • Certificate of Naturalization (N-550 or N-570)
  • Certificate of U.S. Citizenship (N-560 or N-561)
  • Office of Refugee Resettlement Verification of Release Form

OR

List B

Submit a copy of ONE

  • Birth certificate
  • Social Security card
  • Marriage certificate
  • Divorce decree
  • Employer Identification card
  • High school diploma
  • College diploma
  • High school equivalency diploma
  • Property deed or title

OR

List C

Submit a copy of ONE

  • Hospital or clinic record*
  • Doctor’s record*

*Applies to applicants 18 and younger only

Attestation. I attest, under penalty of perjury, that to the best of my knowledge the information in and submitted with this form is true and correct.

Your Signature
Clear Signature
MM slash DD slash YYYY

NEED HELP WITH THIS FORM? Call us at 1-855-355-5777. TTY users should call 1-800-662-1220 or 1-877-662-4886 for TTY in Spanish.