Info Agency Main Banner Content
- DFR: Administrative appeal & hearing request form
- DFR: Authorized representative for health coverage form
- DFR: Authorized representative for SNAP (food assistance and cash assistance)
- DFR: Authorization for disclosure of personal and health information
- DFR: Becoming an authorized representative
Protective Payee for Hoosier Works Card 49884
Allows the TANF recipient to grant permission to another person to be a protective payee for TANF. The protective payee must also complete the form in order to receive a Hoosier Works card to access the client's TANF benefits.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228
Used to apply for the Medicare Savings Program for low income Medicare beneficiaries to help pay their Medicare Part B premium, coinsurance and deductibles.
Application For Medicare Savings Program SF 49921 (QMB, SLMB, QI) (Spanish version)
Applicant Job Search Rights and Responsibilities 48191
Explains the rights and responsibilities to the TANF & SNAP recipients who are referred for a job search.