DETERMINATION OF MEDICAID DISABILITY SOCIAL SUMMARY
State Form 1111 (R9 / 12-05) / OMPP 0251B
ALL 8 SECTIONS MUST BE COMPLETED.
The personal information requested on this form will be used in the determination of the applicant's entitlement to or continued receipt of Medical Assistance administered by the Office of Medicaid Policy and Planning. Disclosure by the applicant of the information requested is mandatory pursuant to the provisions of I.C. 12-15 et seq. Non-disclosure of the information requested will hamper and possibly prevent the delivery of assistance to the applicant. All personal information collected on this form will be treated as confidential pursuant to 470 IAC 1-2-7 and 470 IAC 1-3-1.
SECTION 1. IDENTIFYING INFORMATION
Name of applicant Case number Date of birth (month, day, year) Social Security