Forms

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Complete List of  Employer Tools and Resources	Complete List of Employee Tools and Resources	Complete List of Individual Tools and Resources	Complete List of Agent Tools and Resources
Agent of Record Form Electronic Funds Transfer (EFT) Form  Employer Application  Employer Change Form    Employer Contract Cover Sheet Open Records Request Form Staff Listing Form	Authorization to release Medicaid records Open Records Request Form Out of Pocket Expense Claim Reimbursement Form Self-Employment Attestation Form - English | Spanish Subscriber Change Form    Subscriber Third Party Liability Form	Authorization to release Medicaid records  Open Records Request Form Out of Pocket Expense Claim Reimbursement Form    Request for a Fair Hearing  Subscriber Change Form    Subscriber Third Party Liability Form	Agent of Record Form   Cover Sheet Employee Anonymous Household Survey for the Employer  Open Records Request Form Order Brochures