Free 06533.FH11 - Indiana

REQUEST FOR MEDICAID EXPENDITURES
State Form 6533 (R8 / 7-03) / OMPP 1042

MAIL TO:

FRAUD INVESTIGATION AND ESTATE RECOVERY ONLY FAMILY AND SOCIAL SERVICES OFFICE OF MEDICAID POLICY AND PLANNING (MS07) 402 W. Washington Street Indianapolis, IN 46204-2739 Telephone: 1-317-233-0218 FAX: 1-317-232-7382 EFFECTIVE DATE

County requesting: Address (number and street, city, state, ZIP code)

Telephone number

FAX number

RECIPIENT I.D. NUMBER

NAME AS RECORDED ON APPLICATION

DISCONTINUED DATE

SOCIAL SECURITY NUMBER

TOTALS

CHECK ONLY NECESSARY ITEMS:
Name of person requesting information Reason for request:

Provider list required Itemized printout required

Summary total printout only Total claims paid only

Certification required
Telephone number