Skip to Main Content

Non-Contracted Provider Set-Up

W9 Form * Please attach a completed W9. Please submit enrollments through your Provider Relations staff member if you bill with a SSN as your TIN.

Is this an update or a new submission? *

Yes, we are already set-up with MHS No, we have not been set up with MHS before

Provider Indiana Medicaid # *

Group/Facility Name *

Group Indiana Medicaid # *

Practitioner Name

First Name *

Last Name *

Practitioner Gender *

Male Female N/A (Facility)

Practitioner Email Address

Tax ID # *

Individual NPI # *

Group NPI # *

Primary Taxonomy Code *

Specialty

Billing Address

Street Address

City

Zip / Postal Code

State

Billing Address Phone

Service Location Address

Street Address

City

Zip / Postal Code

State

Service Location Phone

Contact First Name *

Contact Last Name *

Contact Title *

Contact Phone *

Contact Email *