Hhs.texas.gov
HIPP Fax Cover Page Use this cover page when faxing things to the Health Insurance Premium Payment program (HIPP). Fax toll-free to HIPP: 1-866-409-1188 1. Fill out the following (please print): ? Total pages in fax (include cover page):_____________________ ? Medicaid case number: __________________________________ ? Your name:___________________________________________ ? Phone: ( ) ? E-mail:_______________________________________________ 2. Circle what you are faxing to HIPP: ? Proof of premium payment for the month of __________________ ? Rate sheet ? Summary of benefits ? Explanation of benefits (EOB) ? Copy of insurance card ? Other: _________________________________________________ Allow 2 work days for us to review the fax. ................
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