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Enrollment in the Health Benefits for Immigrant Adults (HBIA) program will be temporarily paused effective July 1, 2023.

Enrollment in the Health Benefits for Immigrant Seniors (HBIS) program will be temporarily paused effective Nov. 6, 2023.

Paper Medical Forms Request

NOTE: Providers have the option to bill the Department electronically, which is the Department’s preferred method for claim submission. Although paper claim forms are available, the Department strongly encourages providers to utilize the Medical Electronic Data Interchange Internet Electronic Claims (MEDI IEC) System to submit claims, as well as to verify eligibility, view claims status, download remittance advices, and access other HFS information online through a web interface.

The Department also encourages providers to utilize the electronic forms repository on the HFS Forms webpage. These forms are in a PDF-fillable format unless otherwise indicated. These forms may be completed online, printed, and mailed to the appropriate area of the Department. Certain claim forms are specifically identified as “Example Only” and cannot be completed and mailed to the Department.

If ordering paper forms, please limit the quantity of forms and envelopes requested to an amount that would be used in a 3-month period.

Enter the quantity of the forms being requested. When ordering your 3 month supply, please be sure to indicate the total number of individual forms or envelopes needed in the Quantity column, not the number of boxes, cases or packages. Please verify you have entered accurate information in the required fields.

Forms and Envelopes Out of Stock

The following Forms/Envelopes are currently out of stock. If you are ordering these items expect a delay in processing this portion of your request. Please do not reorder out of stock items. Backorders will be automatically filled when stock is available.

  • Envelope 2244

Electronic Format Only

No longer available in the warehouse:

  • HFS 2292
  • HFS 1409

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