Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- 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. 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: 1/2007
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.
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.
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.
The notice is automatically generated out of TIERS monthly and mailed directly to the client.