Hipp Fax Cover Page Template

HIPP Fax Cover Page

Use this cover page when faxing things to the Health Insurance Premium 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: (

)

•

E-mail:_______________________________________________

2. Circle what you are faxing to HIPP:

• Proof of premium 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.

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Parent category: Business