Free Microsoft Word - Plan POWER Acct Status Form Final Final - Indiana

*DFRAFAE01*

Healthy Indiana Plan POWER Account Payment Status
State Form 53427 (11-07) / HIP 2518

Health Plan Provider: Representative Name: Phone Number: Date:

Fax or Mail to:

FSSA Document Center P.O. Box 1630 Marion, IN 46952 Fax #: 1-800-403-0864

POWER Account Payment / Non-Payment
Complete payment or non-payment information below for each HIP individual in this case

Member Name:

Recipient ID:

Payment Status:
First Payment Received From Member No Initial Payment Received From Member No Longer Receiving On-Going Payments From Member Date of First Payment:

Member Name:

Recipient ID:

Payment Status:
First Payment Received From Member No Initial Payment Received From Member No Longer Receiving On-Going Payments From Member Date of First Payment:

Note: If this form is faxed to the FSSA Document Center, do not send by mail.

DFRAFAE01