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_____________ REGIONAL OFFICE Appendix A-16-5-RB287 DIVISION OF MEDICAID

(DATE) (ADDRESS) (CITY,STATE,ZIP)

(NAME) (ADDRESS)

ID#: 000000000000000 (CITY,STATE,ZIP)

SSN: 000-00-0000

DIVISION OF MEDICAID

NOTICE OF TERMINATION OF MEDICAID

The Mississippi Division of Medicaid has been notified by the Social Security Administration that you failed to cooperate in assigning your third party medical payments to the Division of Medicaid. As a result, your Medicaid benefits will be terminated effective (DATE).

If you disagree with the decision made to terminate your Medicaid based on the reason cited above, you may notify us in writing to request a hearing in this matter. We must be notified within ten (10) days of the date of this notice in order for your Medicaid benefits to continue through the hearing process.

Per Federal (P.L. 98-39, Section 2367) and State laws, it is mandatory that you assign your third party medical payments (medical insurance) to the Medicaid agency in order to remain eligible for Medicaid benefits.

Send your written request for a hearing to:

Office of Eligibility

Division of Medicaid

550 High Street

Suite 1000

Jackson, MS 39201-1399

Enclosure: Medicaid Notice of Non-Discrimination