Health Insurance Referral Form

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

Tracking ID:
(Please include the tracking id from the lead letter form.)
* Recipient Last Name:		* Recipient First Name:
Recipient Last Name is required.		Recipient First Name is required.
Medicaid ID#:		Gold Card Number:
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.
SSN:
Enter a valid SSN.
* Insurance Company Name:
Insurance Company Name is required.
* Policy Number:
Policy Number is required.
* Policy Begin Date:		* Policy End Date:
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.
Group Number:

* Insured's Last Name:		* Insured's First Name:
Insured's Last Name is required.		Insured's First Name is required.
Employer's Name:

Employer's Address 1:		Employer's Address 2:

City:		State:

Zip Code:		* Contact Email:
Enter a valid Zip Code (XXXXX or XXXXX-XXXX).

* REASON FOR REFERRAL: (PLEASE SUPPLY AS MUCH INFORMATION AS POSSIBLE)

	The recipient's Medicaid eligibility file does not list the policy above.
	Insurance documentation gives information that should be used to update Medicaid's files, such as the following:
	Recipient has never been covered by the policy.
	Recipient's coverage ended (date) Please enter valid date (MM/DD/YYYY).
	Policy lapsed (date) Please enter valid date (MM/DD/YYYY).
	Carrier has changed; new carrier is
	Other

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

Please enter correct catchphrase.

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Health Insurance Information Referral Form