FSSA state form 55367 explains the rights and responsibilities of an individual applying for an Indiana Health Coverage Program (IHCP). It is very important that you explain this document to the individuals we assist and give them a copy for their records. The document prints when you choose the option to “Print Application” after you submit an online application.
Please follow the directions below:
- If completing an online application with the individual present, please give a copy of the Rights & Responsibilities (R&Rs) to the individual. You should have the option to print a copy of the application after you submit it and the R&Rs form should be with it.
- If completing an online application without the individual present, please print the application for your records and then go back and choose the “Mail Application” option. Enter the applicant’s mailing address. The Rights and Responsibilities document will be sent to the applicant with this copy.
- You can also print off the generic document here.
When appropriate, you should also give the individual a copy of:
- Patient Request for Assistance
- HIP Fast Track Payment Consent Form
- PE Approval letter
- SSA Authorized Rep Form
Remember: You are NOT allowed to give patients copies of medical records that we have obtained using a ClaimAid release form for the purpose of assisting with a health coverage application.