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Indiana Services Request Cover Sheet
Category:
State:
Multi-State
Control #:
US-143-AZ
Format:
Word;
PDF;
Rich Text
Instant download
Description
How to fill out Services Request Cover Sheet?
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FAQ
Check the status of an application You can check the status of your application online or by calling 1-800-403-0864. You will need to have your case number to check the status of your application.
Income / family size Family sizeIncome limit (per month)2$3,5013$4,4144$5,3255$6,237
Your Medicaid office may ask you to show the following: Proof of date of birth (e.g., birth certificate) Proof U.S. citizenship or lawful residence (e.g., passport, drivers license, birth certificate, green card, employment authorization card)
The MID number can be found on the front of your Hoosier Health Card.
Establishing an Authorized Representative with the state The form needs to be signed by you and the person you authorize as your representative. It should then be filed with the state by fax to 800-403-0864 or delivered by mail or in person to your local county office.
For any further queries, please contact Provider enrollment at 1-800-457-4584.
The following eligibility verification tools can be used to verify the status of a member's eligibility for current and past dates of service. IHCP Provider Healthcare Portal. ... Interactive Voice Response (IVR) System. ... 270/271 Eligibility Inquiry and Response Transaction - Batch or Interactive.
Fax: 800-403-0864 or deliver or mail to your local county office.
