Downloading a Form to Your Computer

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC application. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 

Effective Date: 1/2007

Availability

Form 0052 is pre-populated and auto-generated out of TIERS and mailed directly to the client. Form 0052 is available to staff with TIERS access only.

Instructions

Updated: 1/2007

Purpose

To notify a Medicaid Buy-In client that:

 

  • a partial premium payment was received and the date it was received.
  • a partial premium payment will be returned within 60 days.
  • a full month's premium payment must be received in one payment.

Procedure

When to Prepare

Form 0052 is pre-populated and auto-generated out of TIERS and mailed directly to the client. Form 0052 is available to staff with TIERS access only, under Correspondence, View History Corres, on the left navigation bar.

 

Number of Copies

Staff with TIERS access can print a copy, if a client requests one. It may be mailed or given directly to the client.

 

Transmittal

The notice is automatically generated out of TIERS monthly and mailed directly to the client.