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Program, a Medical Insurance Questionnaire (State Form 46771) must be completed with the member and current health insurance information should be entered on the Third-Party Liability Information Details- screen. If the policy premium information indicates a high-cost diagnosis, or above-threshold annual medical bills, a request for Medical Resource Information (Form 3510) should be mailed to the member’s employer. Upon receipt of the fully completed 3510, worker submits the questionnaire and 3510 to Gainwell TPL Unit for final eligibility determination. Forms should be faxed or mailed to: Gainwell TPL Unit P.O. Box 7262 Indianapolis, IN 46207-7262 Fax: 866-667-6579

Note: DFR and member will receive system-generated approval or denial notice from the TPL unit.

1 IC 12-15-1-24(a) 2 42 CFR 435.919(f)(4)(iii)(B) 3 8 U.S.C. § 1613 4 501 (e) of the Refugee Education Assistance Act of 1980 5 8 CFR 320.2 6 42 CFR 435.956(b)(4) and 42 CFR 457.380(b)(1)(ii) 7 Section 5006(a), (b) and (c) of the American Recovery and Reinvestment Act 8 42 CFR 435.601(b) 9 Public Law 98-94 of the Per Capita Act and 45 CFR section 232.20(a)(4)(ii)(e) 10 Section 5006(c) of the American Recovery and Reinvestment Act 11 25CFR 290.2 12 Public Law 98-94 of the Per Capita Act and 45 CFR section 232.20(a)(4)(ii)(e) 13 42 CFR 435.601(b) 14 Section 5006 (b) of the American Recovery and Reinvestment Act 15 Section 5006(a) of the American Recovery and Reinvestment Act Recovery Act 16 8 U.S.C. § 1613(b)(1)(D) 17 42 U.S.C. § 1320b-7(d)(3) 18 8 U.S. Code § 1613 19 8 U.S. Code § 1612 20 8 U.S. Code § 1612 21 8 U.S. Code § 1101 and 8 U.S. Code § 1101(a)(27) 22 Department of Defense Appropriations Act of 2010 (Section 8120, P.L. 111-118) 23 8 U.S. Code § 1101 24 42 USC 1395dd(e)(1)