173i Instructions for Form 173: Verification Checklist | Medicaid

Form 173 is used to request information and verification needed to determine eligibility.

Form 173 is printed on NCR paper and is available by order from the State office. If hard copies of the Form 173 are temporarily unavailable, this form is also available online at Form 173 and may be printed locally.

Complete the basic case and client specific information at the top of the form. Enter the client’s name and mailing address in the upper left portion of the form if the form is being mailed to the AU.

Complete the remainder of the form as needed.

Mail or give the original to the AU, file the copy in the case record.