SFN 566, “Medicaid Questionnaire and Assignment” 510-03-100-60

(New 7/1/2014 ML #3404)

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This form is used to obtain information from the recipient if other sources of payment are available for recovery of Medicaid funds.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (42 kb pdf)

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.