The Transmittal Form can be used to notify DOM that your office represents a Medicaid beneficiary who has an injury claim. It will begin the process of verifying whether Medicaid has a claim, the amount of the Medicaid claim, and the resolution of the claim. Simply complete the form and fax it to the Subrogation Unit at the number below. If you would prefer, you can fax a letter of representation on your firm’s letterhead.
Attn: Subrogation Unit
Medical Authorization Form
If you would like the DOM Subrogation Unit to provide your attorney, legal representative, or claim adjuster with a list of the providers paid for services related to your accident or injury, please print the following form and sign, date, and fax it to: 844-388-0653.