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Existing Contracted Entity

Practitioner Name


Degree (select one) *






Enrolling in Hoosier Healthwise? *


If yes, enrolling as: *




Enrolling in Healthy Indiana Plan? *


If yes, enrolling as: *




Enrolling in Hoosier Care Connect? *


If yes, enrolling as: *




Enrolling in Ambetter from MHS? *


If yes, enrolling as: *




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


Age Restrictions *


Hospital Affiliations:


Have Admitting Privileges *
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 *




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


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



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


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



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








Enrollment Requested By: