Report Casualty Settlements/Unreported Income

Online Reporting Form

To report a casualty settlement such as money received due to an accident or trauma or other income for DSS recovery, please fill out the online form below as completely as possible.

Personal Information

Name of Medicaid Recipient:

Address of Recipient:

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City, State and Zip:

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Type of Injury, if applicable:

Date of Injury, if applicable:

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Name of Recipient's Attorney:

Name of Alleged Liable Third Party or Source of Unreported Money:

Please Provide the Following Information

Narrative Description of Injury Circumstances:

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Do you wish to remain anonymous?

Yes

If No, please provide the following information:

Your Name:

Your Address:

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City, State and Zip:

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Phone Number:

Please complete the Captcha box below so we know you're a real person

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Report Casualty Settlements/Unreported Income

Online Reporting Form

Personal Information

Please Provide the Following Information

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