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Behavioral Health Existing Contracted Entity

Practitioner Name

Degree (select one) *

Enrolling in Hoosier Healthwise? *

Enrolling in Healthy Indiana Plan? *

Enrolling in Hoosier Care Connect? *

Enrolling in Ambetter from MHS? *

Do you ONLY provide care in a facility setting?
(i.e. hospital-based, hospitalist, etc.)

Age Restrictions *

Hospital Affiliations:

Have Admitting Privileges (Psychiatrists only) *
If yes, please complete Hospital Information on attached enrollment form.

Have Relationship Privileges *
If yes, please complete Hospital information on attached enrollment form.

Utilize Hospitalists *

Enrollment Requested By: