POMS: SI CHI01401 001 - (IN) Indiana State 2026

1. Click ‘Get Form’ to open the POMS: SI CHI01401 001 - (IN) Indiana State in the editor.
2. Begin by filling out the Applicant Information section. Enter your name, address, Social Security Number, and phone number. Indicate if you are requesting an extended payment plan.
3. Provide your date of birth and email address, along with your cell phone number for contact purposes.
4. In the Employment Information section, specify your employment status (Employed/Retired/Disabled), current employer details, position, and annual income.
5. Next, complete the Household Co-Applicant Information if applicable. Fill in their name, date of birth, SSN, phone number, and current address.
6. List any additional household members along with their relationship to you, date of birth, and income if applicable.
7. Fill out the Accounts Related to Application Request section by providing patient name, account number, date of service, and amount owed.
8. Lastly, detail any other assets or sources of income in the designated area before certifying that all information is accurate by signing and dating the form.

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