Indiana
Application for Medicare Savings Program (QMB, SLMG, QI) 49228
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
- 49228
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Application for Medicare Savings Program (QMB, SLMG, QI) 49228
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
- Medicare Savings Program
DFR: Forms - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- Medicare Savings Program
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- If this form is being signed by an authorized representative for the applicant, an Authorized Representative form must be included when filing this application. State Form 55366 can be downloaded from www.in.gov/iara.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- How to submit
- If you received this application in the mail, you may return it to us after you fill it out. Send it to: FSSA Document Center, PO Box 1810, Marion, IN 46952
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- Documents to include
- You will need to provide copies of certain documents to help u s determine your eligibility such as: Your Medicare card; Your most recent statements for all bank accounts, annuities, stocks, bonds, et c.; Property deeds (for property that is not the home you are living in); Life insurance policies; Funeral trust documents; Proof of income; Immigration documents for lawful immigrants; Identification card for other health insurance such as Medicare supplement. If you do not have all of the doc uments that we need, we will a s s i s t y o u i n g e t t i n g t h e information.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- Languages
- English
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - 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=5622
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R6 / 4-19
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- Signature
- To apply, please fill out both sides of the attached applicati on. If there are parts that you do not understand, it is okay to leave them blank. However, yo u must complete section 1 and sign section 13.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
I certify under penalty of perjury, that all of the information I have provided is complete and correct to the best of my knowledge and belief, and that I have received the “Rights and Responsibilities under the Medicaid and Medicare Savings Programs.”
Application for Medicare Savings Program (QMB, SLMG, QI) 49228 - Reviewed 2026-11-02
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