Indiana
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372
No One Left Outside provides source-based information. The issuing agency or plan decides eligibility, acceptance and availability.
Source / last checked DFR: Forms - 2026-11-02
- Form number
- 55372
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372
DFR: Forms - Reviewed 2026-11-02
- Issuing agency
- Indiana Family and Social Services Administration (FSSA); this form appears in the DFR forms catalog.
DFR: Forms - Reviewed 2026-11-02
- Program
- health coverage
DFR: Forms - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- COBERTURA DE SALUD
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Not listed yet. Call to confirm.
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- Not listed yet. Call to confirm.
- Languages
- Spanish edition
DFR: Forms - Reviewed 2026-11-02
- Official page
- https://www.in.gov/fssa/dfr/forms-documents-and-tools/forms
DFR: Forms - Reviewed 2026-11-02
- Direct form link
- https://forms.in.gov/Download.aspx?id=11319
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R12 / 12-25
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372 - Reviewed 2026-11-02
- Signature
- Not listed yet. Call to confirm.
- Accessibility
- '...al (800) 368-1019 o para las llamadas TDD, (800) 537-7697.'
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372 - Reviewed 2026-11-03
- What the form says
13. Se requiere que usted suministre la información completa y correcta a su mejor saber y entender. La persona que reciba los beneficios mediante el suministro intencional de información falsa o sin haber reportado información puede ser procesada criminalmente de acuerdo con la ley estatal o federal.
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372 - Reviewed 2026-11-02
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