All files are available as Adobe Acrobat PDF unless otherwise stated.

Provider Enrollment

• Non Contracted Provider Set-Up Form,
  You can also use the online form
• PMP Disenrollment Form
• Billing Address Update Form
• Hoosier Healthwise, Healthy Indiana Plan
  and Care Select Provider Enrollment Form
• Hoosier Healthwise and Healthy Indiana Plan Hospital and Ancillary Credentialing Form

Claims

• Claim Adjustment Request Form
• Informal Claim Dispute or Objection Form

Prior Authorization

• Home Health Medical Clearance Forms
• IHCP Prior Authorization Form Please call in prior authorization requests for prompt service.

Care Management

• Behavioral/Physical Health Coordination Form
• Behavioral Health Disease Management Referral Form
• Behavioral Health Disease Management Report Form
• Diabetic Flowsheet
• MemberConnections® Referral Form
• Care/Case/Disease Management Request
• Indiana’s Tobacco Quitline Consent Form

Member Management

• Full Panel Add Request Form
• In-Office PMP Change Request
• Member Disenrollment Form
• Hold Panel Add Request Form
• PMP Selection & Pre-Birth Selection Form

Pharmacy

• Pharmacy forms are now located on the Indiana Medicaid Web site:
  Indiana Medicaid Pharmacy Forms
• 17P Pregnancy Reimbursement Form

To request a printed copy of one of these forms, please call Provider Services.