Forms
All files are available as Adobe Acrobat PDF unless otherwise stated.
Provider Enrollment
- Non Contracted Provider Set-Up Form
- Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Provider Enrollment Form (PDF)
- Provider Specialty Profile Form (PDF)
- Behavioral Health Additional Forms: Provider Specialty (PDF), and HSPP Attestation (PDF)
- Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Hospital and Ancillary Credentialing Form (PDF)
Claims
- Informal Claim Dispute or Objection Form (PDF)
- Behavioral Health Informal Claim Dispute or Objection Form (PDF)
Prior Authorization
- IHCP Prior Authorization Form (PDF) - Please call in prior authorization requests for prompt service.
- Prior Authorization Provider Handout (PDF)
Prior Authorization for Residential and Inpatient SUD Treatment
- Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form (PDF)
- Initial Assessment Form for Substance Use Disorder Treatment Admission (PDF)
- Reassessment Form for Continued Substance Use Disorder Treatment (PDF)
Pay for Performance
Care Management
- Adult Health Maintenance Form (PDF)
- Behavioral/Physical Health Coordination Form (PDF)
- Diabetic Flowsheet (PDF)
- MemberConnections® Referral Form (PDF)
- Care/Case/Disease Management Request (PDF)
- Indiana’s Tobacco Quitline Consent Form (PDF)
EPSDT Templates
- Newborn (PDF)
- 1-2 Months (PDF)
- 3-4 Months (PDF)
- 5-6 Months (PDF)
- 7-9 Months (PDF)
- 10-12 Months (PDF)
- 15 Months (PDF)
- 18 Months (PDF)
- 24 Months (PDF)
- 30 Months (PDF)
- 3-4 Years (PDF)
- 5-6 Years (PDF)
- 7-10 Years (PDF)
- 11-14 Years (PDF)
- 15-21 Years (PDF)
- Well-Child Documentation Tips (PDF)
Member Management
The Full Panel Add and Hold Request form and Member Disenrollment form are now available on the Provider Portal. Copies of completed paper forms are no longer accepted via fax or email. Please login to your portal account to complete these forms.
- Outreach Items Request Form (PDF)
Please reach out to your Provider Relations Representative to order MHS brochures and other office items. - Community Partner Request Form (PDF)
- MemberConnections Referral Form (PDF)
Pharmacy
- Medication Prior Authorization Form (PDF)
- General Specialty Prior Authorization Form (PDF)
- Disease/Drug Specific Prior Authorization Forms
- Request a Drug to Be Added to the PDL (PDF)
To request a printed copy of one of these forms, please call Provider Services.
Ambetter Manuals & Forms
For Ambetter information, please visit our Ambetter website