Existing Contracted Entity

Degree (select one) *

MD DO DPM NP Other

Enrolling in Hoosier Healthwise? *

Yes No

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Enrolling in Healthy Indiana Plan? *

Yes No

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Enrolling in Hoosier Care Connect? *

Yes No

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Enrolling in Ambetter from MHS? *

Yes No

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Enrolling in Allwell from MHS *

Yes No

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Do you ONLY provide care in a facility setting?

Yes No

(i.e. hospital-based, hospitalist, etc.)

Have Admitting Privileges *

Yes No

If yes, please complete Hospital Information on attached enrollment form.

Have Relationship Privileges *

Yes No

If yes, please complete Hospital information on attached enrollment form.

Utilize Hospitalists *

Yes No

When referring patients to the hospital, do you have admitting privileges?

Yes No

When referring patients to the hospital, do you have relationship privileges?

Yes No

When referring patients to the hospital, do you utilize hospitalists?

Yes No