SI CHI01730.040 (IN, MI, OH, WI) Assignment of Rights and Third Party Liability (RTN 402 -- 03/2007)
See SI 01730.040 – Assignment of Rights (AOR)
See SI 01730.045 – Third Party Liability (TPL)
See SI 01730.050 – Exhibits, Assignment of Rights and Third Party Liability
Address of State Agency to mail the Third Party Liability Information Statement (Form SSA-8019), where required. Refer
to TPL reference above.
Indiana Family & Social Services Administration
Office of Medicaid Policy & Planning
402 W. Washington Street, Room W374 MS07
Indianapolis, IN 46204
Attn: Joe Moser, Director of Medicaid
Michigan Department of Community Health
Third Party Liability Division
P.O. Box 30479
Lansing, MI 48909-7979
Attn: Keelie Honsowitz, Manager
Health Insurance Liability Section
Ohio Department of Medicaid
Claims Operations
50 West Town Street, 4th Floor, B419
Columbus, OH 43215–4173
Attn: Patrick A. Tighe, Bureau Chief
HP, Coordination of Benefits (COB) Unit
P. O. Box 6220
Madison, WI 53716