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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: