Medicaid Program Current, Past, Or Anticipated Wage Verification - Louisiana Department Of Health

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BHSF Employer
Rev. 04/01
Prior Issues Obsolete
IV
MEDICAID PROGRAM
Current, Past, OR Anticipated Wage Verification
TO:
FROM: Bureau of Health Services Financing
DATE:
Name of Applicant/Recipient
SSN
Case ID No.
You are authorized to provide any information concerning my current, past, or anticipated
employment and insurance coverage to Louisiana’s Medicaid Program.
Signature of Applicant/Recipient
Date
The individual named above applied for/is receiving
.
It is necessary to verify his/her current or anticipated income and health insurance coverage to
determine Medicaid eligibility. A form is provided on the back of this letter for your convenience in
providing this information. If this individual has not actually started to working, please anticipate as
accurately as possible what his/her wages will be and whether he/she will have insurance coverage.
We are reviewing the past participation of the individual named above in the Medicaid Program.
We must have exact information to complete our investigation.
We understand that the individual named above was employed by your firm during the period 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 providing this information. Please check the Social Security number we have
provided carefully against your records.
We have contacted your employer,
, concerning your
employment there from
to
. Our inquiries have
not been answered and we are unable to determine the actual
which you received. Please contact your employer and have
him fill out the back of this letter.
Please return the information requested above to us by
.
Enclosed is a stamped, self-addressed envelope for your convenience in replying.
Thank you for your cooperation. Your assistance is appreciated.
Sincerely,
Agency Representative

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