Authorized Representative Form Medicaid Indiana

Authorized Representative Form Medicaid Indiana

It is a legal form published by the Indiana Department of Family & Social Services Administration – an Indiana government agency. To date, no separate form submission guidelines are provided by the issuing service. Download a printable version of State Form 55366 (DFR2123HC) by clicking on the link below, or browse other documents and templates provided by the Indiana Department of Family & Social Services Administration. Press the PRINT button to print only the current page. Download the document to your desktop, tablet or smartphone for complete printing. .