Skip to Main Content
Home
Find a Provider
Portal Login
Events
Careers
Contact Us
language
English
Spanish
Enter Keyword
Search
For Members
Wellcare by Allwell
Ambetter from MHS
Healthy Indiana Plan
Hoosier Care Connect
Hoosier Healthwise
Wellcare Complete
For Providers
Login
Behavioral Health Providers
Clinical & Payment Policies
Dental Providers
Email Sign Up
Enrollment and Updates
Opioid Resources
Pharmacy
Prior Authorization
Provider Education & Training
Provider News
Provider Resources
QI Program
Get Insured
Login
Find a Provider
For Members
Wellcare by Allwell
Ambetter from MHS
Healthy Indiana Plan
Login
Benefits & Services
Caregiver Resources
Community Connect
Find a Provider
Health & Wellness
How to Enroll
Member Handbook
Member News
Member Resources
Opioid Resources
Redetermination
Hoosier Care Connect
Login
Benefits and Services
Caregiver Resources
Community Connect
Find a Provider
Foster Care Resources
Health & Wellness
How to Enroll
Member Handbook
Member News
New Member Checklist
Member Resources
Opioid Resources
Redetermination
Hoosier Healthwise
Login
Benefits and Services
Caregiver Resources
Community Connect
Find a Provider
Foster Care Resources
Health & Wellness
How to Enroll
Member Handbook
Member News
Member Resources
Opioid Resources
Redetermination
Get the Most from Your Coverage
Wellcare Complete
For Providers
Login
Behavioral Health Providers
BH Trainings
BH Forms
Clinical & Payment Policies
Dental Providers
Email Sign Up
Enrollment and Updates
Demographic Update Tool
Become a Contracted Provider
Contracted Enrollment Request
Provider Effective Date Policy
Opioid Resources
Pharmacy
Drug Search Tool
Pharmacy Forms
Preferred Drug Lists
Prior Authorization
Medicaid Pre-Auth
Ambetter Pre-Auth
Medicare Pre-Auth
Provider Education & Training
Provider Orientation
Foster Care Training
Clinical Training
Provider News
Provider Resources
Forms
Guides and Manuals
Health Library
Helpful Links
Partnered Member Events
POWER Account
Frequently Asked Questions
Grievance Process
Case and Disease Management
Electronic Transactions
Provider Performance
Resource Center
Newsletters
QI Program
Medical Records
Practice Guidelines
Immunization Information
Report Fraud, Waste and Abuse
Providing Quality Care
Get Insured
About Us
Key Stakeholders
Leadership
School-Based Services
Adopt a School Application
Telehealth Funding Application
Careers
Contact Us
Newsroom
Press Releases
Careers
Privacy Policy
Terms & Conditions
Notice of Privacy Practices
Contact Us
SEARCH
MENU
Go!
Home
Find a Provider
Portal Login
Events
Careers
Contact Us
language
English
Spanish
For Providers
Login
Behavioral Health Providers
BH Trainings
BH Forms
Clinical & Payment Policies
Dental Providers
Email Sign Up
Enrollment and Updates
Demographic Update Tool
Become a Contracted Provider
Contracted Enrollment Request
Provider Effective Date Policy
Opioid Resources
Pharmacy
Drug Search Tool
Pharmacy Forms
Preferred Drug Lists
Prior Authorization
Medicaid Pre-Auth
Ambetter Pre-Auth
Medicare Pre-Auth
Provider Education & Training
Provider Orientation
Foster Care Training
Clinical Training
Provider News
Provider Resources
Forms
Guides and Manuals
Health Library
Helpful Links
Partnered Member Events
POWER Account
Frequently Asked Questions
Grievance Process
Case and Disease Management
Electronic Transactions
PaySpan - EFT/ERA
Provider Performance
HEDIS
Provider Analytics
Resource Center
CAHPS
CLAS Standards
Correct Coding Initiative
Patient Centered Medical Home Model
National Imaging Associates (NIA)
Tobacco Cessation Resources
Ramp Up Success
Newsletters
QI Program
Medical Records
Practice Guidelines
Immunization Information
Report Fraud, Waste and Abuse
Providing Quality Care
Update an IRS Address
Group/Facility Name
*
Error:
This field is required.
Tax ID #
*
Error:
This field is required.
Group NPI #
*
Error:
This field is required.
IRS Address
Street Address
*
Error:
This field is required.
Address Line 2
City
*
Error:
This field is required.
ZIP / Postal Code
*
Error:
This field is required.
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Error:
This field is required.
Please Attach a Completed W9
Items in the trash will be permanently removed after 30 days.
Comments
Update Requested By:
First Name
*
Error:
This field is required.
Last Name
*
Error:
This field is required.
Date
*
Error:
This field is required.
Contact Email
*
Error:
This field is required.
Contact Phone Number
*
Error:
This field is required.
Error:
reCAPTCHA verification failed.
Error:
Please add a Captcha.
Last Updated: 11/09/2023
