Member Forms

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.

HIP Payment Forms

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.