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Existing Contracted Entity

Contract Type *

Medical - Diagnostic Radiology, Pathology, ER Physician, Anesthesiology (non-pain management), CRNA Medical - Other Behavioral Health

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Please do not use this form unless you are one of the following specialties: Diagnostic Radiology, Pathology, ER Physician, Anesthesiology (non-pain management), or CRNA.

If you are enrolling additional specialties, please select Medical (Other) above.

Tax Identification Number *

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Provider/Group NPI (if additional NPIs are needed please submit a new request) *

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Provider/Group Indiana Medicaid Number

Provider/Group Name *

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Provider/Group Specialty *

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Service/Location Name *

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Service/Location Address (only 1 per TIN/GNPI) *

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Service/Location Suite Number

Service/Location City *

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Service/Location State *

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Service/Location Zip *

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Appointment Phone Number *

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Service/Location Main Phone Number *

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Service/Location Main Fax Number

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Billing Name *

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Billing Address *

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Billing City *

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Billing State *

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Billing Zip *

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Billing Phone Number *

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Billing Fax Number

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Practitioner Name

First Name *

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Last Name *

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Practitioner Gender *

Male Female

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Practitioner NPI *

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Degree (select one) *

MD DO DPM NP Other

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If other, what degree?

Practitioner Taxonomy Code *

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Practitioner Email Address *

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Practitioner Specialty *

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Practitioner Indiana Medicaid Number

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Enrolling in Hoosier Healthwise *

Yes No

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Enrolling in Healthy Indiana Plan *

Yes No

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Enrolling in Hoosier Care Connect *

Yes No

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Enrolling in Ambetter MHS IN *

Yes No

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Enrolling in Allwell MHS IN *

Yes No

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Comments

Enrollment Requested By:

First Name *

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Last Name *

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Contact Email *

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Contact Phone *

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Date *

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CAQH Number *

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Practitioner Name

First Name *

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Last Name *

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Practitioner NPI *

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Degree (select one) *

MD DO DPM NP Other

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If other, what degree?

Appointment Phone Number *

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Practitioner Email Address

Practitioner Taxonomy Code *

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Do you offer telehealth appointments? *

Yes No

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Enrolling in Hoosier Healthwise? *

Yes No

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If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

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Maximum Membership/Panel Size

Enrolling in Healthy Indiana Plan? *

Yes No

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If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

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Maximum Membership/Panel Size

Enrolling in Hoosier Care Connect? *

Yes No

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If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

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Maximum Membership Panel Size

Enrolling in Ambetter from MHS? *

Yes No

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If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

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Maximum Membership Panel Size

Enrolling in Allwell from MHS *

Yes No

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If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

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Maximum Membership/Panel Size

Do you ONLY provide care in a facility setting?

Yes No

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

Age Restrictions*

None 0-2 Years 0-12 Years 0-20 Years 3+ Years 13+ Years 0-17 Years 13-20 Years 17+ Years 21+ Years 65+ Years

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Group NPI

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Group Medicaid Number *

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Alpha Suffix

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TIN *

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Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

MCE Universal Enrollment Form (for HHW, HIP and/or HCC, or for all products)

Practitioner Enrollment Form (Ambetter/Allwell only)

If a midlevel practitioner, please attach a copy of your collaboration agreement.

Comments

Enrollment Requested By:

First Name *

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Last Name *

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Contact Email *

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Contact Phone *

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Date *

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Error: Please complete the captcha

CAQH Number *

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Practitioner Name

First Name *

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Last Name *

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Practitioner NPI *

Error: This field is required.

Degree (select one) *

MD PhD HSPP LCSW Other

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If other, what degree?

Appointment Phone Number *

Error: Please enter a 10 digit phone number.

Practitioner Email Address

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Primary Taxonomy Code *

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Do you offer telehealth appointments? *

Yes No

Error: This field is required.

Enrolling in Hoosier Healthwise? *

Yes No

Error: This field is required.

Enrolling in Healthy Indiana Plan? *

Yes No

Error: This field is required.

Enrolling in Hoosier Care Connect? *

Yes No

Error: This field is required.

Enrolling in Ambetter from MHS? *

Yes No

Error: This field is required.

Enrolling in Allwell from MHS? *

Yes No

Error: This field is required.

Do you ONLY provide care in a facility setting?

Yes No

Error: This field is required.

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

Age Restrictions*

None 0-2 Years 0-12 Years 0-20 Years 3+ Years 13+ Years 13-20 Years 17+ Years 21+ Years 65+ Years

Error: This field is required.

Group NPI *

Error: This field is required.

Group Medicaid Number *

Error: This field is required.

Alpha Suffix

Error: This field is required.

TIN *

Error: This field is required.

Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

MCE Universal Enrollment Form (for HHW, HIP and/or HCC, or for all products)

Practitioner Enrollment Form (Ambetter/Allwell only)

Additional Forms

Behavioral Health Specialty Profile (PDF)

Please attach a copy of your Behavioral Health Specialty Profile. *

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If a midlevel practitioner, please attach a copy of your collaboration agreement.

Comments

Enrollment Requested By:

First Name *

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Last Name *

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Contact Email *

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Contact Phone *

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Date *

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Last Updated: 03/15/2021

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