Hipp Fax Cover Sheet j1e5o

HIPP Fax Cover Page Use this cover page when faxing things to the Health Insurance Payment program (HIPP).

Fax toll-free to HIPP: 1-866-409-1188 1. Fill out the following (please print): • Total pages in fax (include cover page):_____________________ • Medicaid case number: __________________________________ • Your name:___________________________________________ • Phone: ( •

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E-mail:_______________________________________________

2. Circle what you are faxing to HIPP: • Proof of payment for the month of __________________ • Rate sheet • Summary of benefits • Explanation of benefits (EOB) • Copy of insurance card • Other:_________________________________________________

Allow 2 work days for us to review the fax.