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Effective Date: 



Updated: 8/2001


To request information about an applicant/recipient's health insurance policies.


When to Prepare

The worker sends Form H1253 to insurance companies to get pertinent information about insurance policies.

Number of Copies

The worker completes an original and one copy. (Follow regional instructions.)


The worker sends the original to the appropriate insurance company and keeps the duplicate in the case record. Attach Form H0003, Authorization to Furnish Information, (signed by the applicant, recipient, or responsible person) to the original.

If the insurance company returns the form indicating prescription coverage or nursing home coverage, enter the client number in the "Comments" section and send a photocopy to:

Providers Claim Payment Services
State Office Y-948

Form Retention

Keep the returned original in the case record, according to regional instructions.

Detailed Instructions

Inside Address — Enter the name and address of the insurance company.

Date — Self-explanatory.

Eligibility Specialist — Enter the eligibility specialist's signature.

Office Address and Telephone No. — Self-explanatory.

Applicant/recipient information — Enter insurance policy number(s), names of policy owner and insured person, social security number(s) if known, and any pertinent comments.

To Be Completed by Insurance Representative — Self-explanatory.