Florida Medicaid TPL Recovery Program
Toll Free: 877-357-3268
Fax: 844-845-8354
Email: fltpr@hms.com

Health Insurance Information Referral Form

This form is designed to give the Medicaid program information that can be used to verify or reverify private health insurance coverage for Medicaid recipients.

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Indicates required field.
 
   
(Please include the tracking id from the lead letter form.)

Recipient Last Name is required.

Recipient First Name is required.

Enter a valid 10 digit Medicaid ID.

Enter a valid 8 digit Gold Card Number.

Please enter value for Gold Card Number OR Medicaid ID.

 

Enter a valid SSN.

 
 

Insurance Company Name is required.

 
 

Policy Number is required.

 

Enter a valid Policy Begin Date (MM/DD/YYYY).

Policy Begin Date is required.

Enter a valid Policy Begin Date (MM/DD/YYYY).

Policy End Date is required.

 
 

Insured's Last Name is required.

Insured's First Name is required.

 
 
 
 
 

Enter a valid Zip Code (XXXXX or XXXXX-XXXX).

 
 
  Insurance documentation gives information that should be used to update Medicaid's files, such as the following:
 
 

Please enter valid date (MM/DD/YYYY).

 

Please enter valid date (MM/DD/YYYY).

 
 
Enter the text shown below in to the box provided before clicking Submit.

Captcha

Please enter correct catchphrase.


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