Page 1

O F F I C E O F T H E G O V E R N O R | M I S S I S S I P P I D I V I S I O N O F M E D I C A I D APPA

To:

To Whom It May Concern From: ____________________________________ Regional Medicaid Office Date: Re:

The individual identified above inquired with this office about his/her possible Medicaid eligibility. Based on unverified, self-attested information provided by this individual, he/she would not qualify for Medicaid under any available coverage group.

This is not an official Medicaid decision. In order to receive an official decision to approve or deny Medicaid coverage, this individual must complete and file a full Medicaid application with the MS Division of Medicaid and allow this agency to do a full review of all factors of eligibility.

The Division of Medicaid is providing this information to this individual upon his/her request for an unofficial denial of Medicaid coverage.

APPENDIX PAGE A-12 M E M O