Medicaid lien request form 2026

1. Click ‘Get Form’ to open the Medicaid lien request form in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping.
3. Fill in the Plaintiff's name, Social Security Number (SSN), and Date of Birth. Ensure accuracy as this information is critical for identification.
4. Next, input the Settlement Amount, Date of Incident, NYC File Number (if applicable), and Settlement Date. These details help clarify the context of the lien.
5. Indicate the Index Number and specify the type of injury. If necessary, fax a Bill of Particulars for further clarification.
6. Select whether this is an Updated or Final lien request by checking the appropriate box.
7. Provide details about your firm, including Firm Name, Address, Attorney Name, Email, Telephone, and Fax number.
8. If representing a plaintiff or defendant, include their names and contact information for both parties' attorneys.
9. List each Insurance Company insuring defendants along with their Claim/File numbers.
10. Finally, complete the form by signing and dating it in the designated area before submitting it via fax to ensure timely processing.

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