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Member Forms

Behavioral Health and Physical Health Doctors Working Together

Behavioral/Physical Health Coordination Form (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 (PDF)
Completing this form will allow MHS to share your personal health information with another company or individual that you name.

Revocation of Authorization to Use and/or Disclose Health Information (PDF)
Completing this form will allow you to revoke your approval of MHS sharing your personal health information with another company or individual that you previously named.

Choose a Representative to Appeal

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

Proof of Rollover Services Received

Certification of HIP Preventive Services Received (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.

HIP Payment Forms

Employer, Nonprofit or Other Payer Contribution
Employer and Nonprofit Contribution Form (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 (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 (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.

Contact the State to Report a Change (Address, Phone Number, etc.)

Call the Department of Family Resources (DFR) at 1-800-403-0864 or go to the FSSA Benefits Portal

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. You can request a change once every benefit period.

If you would like this information in print, please call Member Services at 1-877-647-4848.

Last Updated: 10/25/2023