Health & Benefits
Worried about doing this on your own? You may be able to get free legal help.
Medicaid claim inquiry Form link
A form to ask about a medical bill that you think should have been covered by Medicaid.
Can I use this form?
To use this form, you must have been billed for something you think should have been covered by Medicaid. Use this form when medical bills have gone to collections or there is litigation involved.
What do I need first?
To complete this form, you will need:
- The patient's name and social security number,
- The healthcare provider's name and address, and
- The date and a brief explanation of the medical service received.
Last full review by a subject matter expert
May 26, 2021
Last revised by staff
May 26, 2021
Legal Comment
Worried about doing this on your own? You may be able to get free legal help.
Only logged-in users can post comments. Please log in or register if you want to leave a comment. We do our best to reply to each comment. We can't give legal advice in the comments, so if you have a question or need legal help, please go to Get Legal Help.