Indiana
Revocation of Authorization 51736
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
- 51736
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Revocation of Authorization 51736
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
- Indiana Health Coverage Programs
Revocation of Authorization 51736 - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- Indiana Health Coverage Programs
Revocation of Authorization 51736 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Section C: To the member – Please sign the form. Signature: Date: Section D: To the member’s personal representative – Please sign the form and complete the appropriate information If this request is from a personal representative on behalf of the IHCP member, please provide a copy of the documentation to support the representation and complete the following:
Revocation of Authorization 51736 - Reviewed 2026-11-02
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- If this request is from a personal representative on behalf of the IHCP member, please provide a copy of the documentation to support the representation and complete the following:
Revocation of Authorization 51736 - Reviewed 2026-11-02
- Languages
- English
Revocation of Authorization 51736 - 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=8404
DFR: Forms - Reviewed 2026-11-02
- Revision date
- 5-04
Revocation of Authorization 51736 - Reviewed 2026-11-02
- Signature
- Section C: To the member – Please sign the form. Signature: Date: Section D: To the member’s personal representative – Please sign the form and complete the appropriate information If this request is from a personal representative on behalf of the IHCP member, please provide a copy of the documentation to support the representation and complete the following: Personal Representative’s Name: Date: Relationship to IHCP Member: This form must be notarized if submitted by the member’s personal representative.
Revocation of Authorization 51736 - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
I understand that this revocation of my authorization will not affect any action the IHCP or others took in reliance on my authorization before receiving this written notice of my revocation.
Revocation of Authorization 51736 - Reviewed 2026-11-02
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