Member Forms

Choose Your MHS Family Doctor
Doctor Selection Form (Inglés y disponable en Español) (PDF)
Use this form to pick your MHS Doctor, your Primary Medical Provider (PMP). Please enter doctor choices for each person in the family who is an MHS member. You can also use this doctor selection form to pick your baby’s doctor before he or she is born.

Behavioral Health and Physical Health Doctors Working Together
Behavioral/Physical Health Coordination Form (Inglés) (PDF)
It’s important for both your behavioral and physical healthcare providers to know what kind of care you are getting. Keep your doctors connected by taking the Behavioral/Physical Health Coordination form to your next visit.

Get Access to your Personal Health Information
Authorization of the Use and Disclosure of Protected Health Information (Inglés y Español) (PDF)
Completing this form will allow MHS to share your personal health information with another company or individual that you name.

Choose a Representative to Appeal
Authorization for Another Person to Appeal in your Name (Inglés y Español) (PDF)
Completing this form will allow a person that you choose represent you in an appeal for services from MHS.

Forms for Healthy Indiana Plan Members Only

Proof of Rollover Services Received
Certification of HIP Preventive Services Received (Inglés) (PDF)
MHS Healthy Indiana Plan members can take this form to their doctor to complete. The form will tell MHS that you have gotten at least one of the listed required visits to be eligible for POWER Account rollover.

Employer Contribution letter and form
Employer Contribution letter and form (Inglés) (PDF)
Take the Employer Contribution letter, explaining the program, and form to have filled out by your employer.

Employer and Nonprofit Contribution Form
Employer and Nonprofit Contribution Form (Inglés) (PDF)
Employers, Non-profit organizations or others payers may help a Healthy Indiana Plan (HIP) member with some or all of their monthly POWER Account contribution. Complete this form to assist with payment.

Payroll Deduction
Payroll Deduction form (Inglés) (PDF)
Discuss this option directly with your employer to ensure payroll deduction is available at your place of work. Your employer should contact MHS to make necessary transaction arrangements with Member Services.

Automatic Bank Deduction / Electronic Funds Transfer
Electronic Funds Transfer form (Inglés) (PDF)
Complete the Electronic Funds Transfer form and mail it to Member Services. It may take one to two billing cycles for the amount to be deducted from your bank account.

Change of Address, or Requesting Change of Payment Amount for POWER Account
Please view the Report of Change form on the FSSA website: Visit the FSSA Forms page and look for the “Report of Change 44151/FI 2420″ form.

Did you know? if you are a Healthy Indiana Plan member who pays a contribution towards your POWER Account, you have a right to have the payment amount reviewed if you have a qualifying event, such as a change in income or family size. You can request a change once every benefit period.

If you would like this information in print, please contact MHS Member Services.