Wage Verification Request
FROM: Louisiana Medicaid Program__________
Name of Applicant/Eligible
Case ID No.
My signature below gives you permission to provide information about my current, past, or
expected employment and insurance coverage to Louisiana’s Medicaid Program.
Signature of Applicant/Eligible
The person named above applied for or is receiving health coverage through the Medicaid Purchase
It is necessary to verify his/her current or anticipated income and health insurance coverage. A form
is provided on the back of this letter for your convenience in giving us this information. If this person
has not actually started to work, please estimate as accurately as possible what his/her wages will
be and whether he/she will have insurance coverage.
The Medicaid Program is reviewing the past eligibility for Medicaid of the person named above. We
must have exact information for our investigation.
We understand that the person named above was employed by your business from _____________
to _____________. It is necessary that we have exact gross income amounts earned during each
pay period. A form is provided on the back of this letter for your convenience in giving us this
information. Please check the Social Security number we have provided carefully against your
We have contacted your employer, ___________________________________, about your
employment there from _____________ to ______________. The information we asked for has not
been provided. We need your help to find out about the actual ___________________________
that you received. Please contact your employer and have him fill out the back of this letter. We
cannot make a decision about your Medicaid health coverage without this information.
Please return the information requested above to us by _____________. With this letter is a stamped,
self-addressed envelope for you to use.
Thank you for your cooperation. Your help is appreciated.