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: (
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.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business