Medicaid Member Death Report Form

Medicaid Member Death Report Form

Pursuant to Wyoming Department of Health, Division of Healthcare Financing (Wyoming Medicaid) rules, Providers are required to notify the Department of Health, Division of Healthcare Financing of the death of any

Wyoming Medicaid Member in their facility within three (3) working days of the Member's death.

Member Information

Member Name

Member Address

(Prior to entering nursing home.)

Street Address

Social Security Number

Marital Status

Guardian, Next of Kin, or Power of Attorney Information

Member ID

City

Date of Birth Date of Death

State

Zip Code

Contact Name

Contact Address

Street Address

Provider Information

Contact Number

City

State

Zip Code

Provider Name

Contact Number

Provider Address

Street Address

Person Completing Form

Name of Person Completing Form

City

State

Zip Code

Date

Please send the completed form via mail or FAX it promptly to the address below.

Mail completed form to: HMS Third Party Referral (TPR) 5615 High Point Drive Irving, TX 75038 Phone: 1-888-996-6223 (1-888-WYO-MCAD) Email form as an attachment: WYTPR@

WYBMS-Medicaid Member Death Report form

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