Medicaid lien request 2025

1. Click ‘Get Form’ to open the Medicaid Lien Request in our editor.
2. Begin by entering the 'Date' at the top of the form. This is essential for tracking your request.
3. In section I, fill in the 'Plaintiff Name', 'SSN', 'Date of Birth', and 'Settlement Amount'. Ensure accuracy as these details are crucial for processing.
4. Next, provide the 'Date of Incident', 'NYC File #', and 'Settlement Date'. If applicable, include the 'Index Number' and specify the injury type.
5. Indicate whether this is an 'Updated' or 'Final' lien by checking the appropriate box in section II. Then, complete the attorney's details including name, firm name, address, email, telephone, and fax.
6. If representing a plaintiff or defendant, provide relevant names and contact information in section III. This ensures all parties are correctly identified.
7. In section IV, list each insurance company associated with defendants along with their claim/file numbers for comprehensive coverage.
8. Finally, complete section V by signing and dating the form to validate your submission.

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