Free Microsoft Word - HIP Client Report_of_Change Form Final Final - Indiana

REPORT OF CHANGE ­ Healthy Indiana Plan
State Form 53428 (11-07) / HIP 2519

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Mail or Fax Completed Form to:

Name of case

Case number

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

Address (number and name, city, state, ZIP code)

Telephone number where you can be reached: ( )

IMPORTANT INFORMATION Your Social Security number is being requested by this State agency in accordance with 45 CFR 205.52, 7 CFR 273.6, and 42 CFR 435.910. The information obtained on this form is confidential under state and federal regulations, including 470 IAC 1-2-7, 470 IAC 1-3-1, 470 IAC 6-1-1, 405 IAC 11-12, 45 CFR 205.50, 7 CFR 272.1(c), and 42 CFR 431.300. This information will not be released except as permitted or required by law or with the consent of the applicant/recipient. ALL CHANGES MUST BE REPORTED WITHIN 10 DAYS. 1. CHANGE OF ADDRESS
Telephone number ( ) Date moved New address (number and street, city, state, ZIP code)

2.

CHANGE OF PEOPLE IN YOUR HOUSEHOLD Name of Person

In

Out

Date of Birth

Social Security Number

Date of Change

3.

CHANGE IN SOURCE OR AMOUNT OF EARNED INCOME This includes new employment, raises, promotions and access to employer sponsored health insurance. Name or person Type of change Does this employer offer Health Insurance? Yes No Place of employment 4. 5. Start date Hourly wage

Date of change

Expected weekly hours of work

DO YOU WANT US TO RECALCULATE YOUR CONTRIBUTION AMOUNT TO THE HIP COVERAGE? Yes No Note: you are allowed one Recalculation related to income changes from the same job or income from a new job in a 12-month period.

CHANGE IN SOURCE OR AMOUNT OF UNEARNED INCOME This includes child support, Social Security, SSI, unemployment, VA benefits, utility checks, contributions, financial aid, etc. Name of person Type of change New amount $ 6. Frequency of amount: If Other, Specify: Monthly Weekly Other

Date of Change

HEALTH INSURANCE: Does anyone in the household have health insurance coverage including Medicare? (Do Not List Medicaid) Claim Number, Policy or Coverage Start Name of Person Covered Insurance Company Group Number Date

7.

PREGNANCY: Is anyone in the household pregnant? Name of Person Date of Birth Social Security Number Date of Expected Delivery Number of Babies Expected

8.

OTHER CHANGES

9.

Do you expect the changes you have reported to continue beyond this month?

Yes

No

If no, please explain:

Signature
Telephone number where you can be reached: ( )

Date (month, day, year)
Social Security Number

PLEASE ATTACH PROOF OF YOUR CHANGES, IF POSSIBLE. If you have not heard from FSSA within 10 days of turning in your report, please call 1-800-403-0864
(See the back of this form for more information)

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Information About Reporting Changes For Healthy Indiana Plan
YOU MUST REPORT ALL CHANGES WITHIN 10 DAYS FROM THE TIME YOU KNOW ABOUT THE CHANGE (Below are examples of changes you MUST report)

REPORT TO US

When someone MOVES IN or MOVES OUT of your home. When someone in your home gets married, is pregnant, has a baby, or dies. When someone is covered by health insurance. When a divorce is final by court order. When the amount of court-ordered child support you pay changes.

REPORT TO US

When you MOVE.

REPORT TO US
Change in a JOB, a new job, a job ends, an increase or decrease in pay, an employer offers health insurance, or a change in MONEY received such as Child Support or Social Security.
FAILURE TO REPORT CHANGES MAY RESULT IN YOU HAVING TO REPAY BENEFITS

IF YOU HAVE QUESTIONS PLEASE CALL TOLL FREE 1-800-403-0864

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