Forms

All files are available as Adobe Acrobat PDF unless otherwise stated.

Provider Enrollment

• Behavioral Health Additional Forms: Provider Specialty (PDF), and HSPP Attestation (PDF)
• Behavioral Health Facility and Ancillary Demographic Form (PDF)
• Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Hospital and Ancillary Credentialing Form (PDF)
• Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Provider Enrollment Form (PDF)
• Non Contracted Provider Set-Up Form
• Provider Specialty Profile Form (PDF)

Claims

• Medical Claim Dispute/Appeal Form (PDF)

Prior Authorization

• IHCP Prior Authorization Form (PDF) - Please call in prior authorization requests for prompt service.
• IHCP Prior Authorization Form Instructions (PDF)
• Late Notification of Services Submission Form (PDF)
• Prior Authorization Provider Handout (PDF)

Prior Authorization for Residential and Inpatient SUD Treatment

• Initial Assessment Form for Substance Use Disorder Treatment Admission (PDF)
• Reassessment Form for Continued Substance Use Disorder Treatment (PDF)
• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form (PDF)

Pay for Performance

• Faxback Form (PDF)

Care Management

• Adult Health Maintenance Form (PDF)
• Behavioral/Physical Health Coordination Form (PDF)
• Care/Case/Disease Management Request (PDF)
• Diabetic Flowsheet (PDF)
• Indiana’s Tobacco Quitline Consent Form (PDF)
• Medically Frail Referral Form (PDF)
• MemberConnections® Referral 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.

• Key Provider Partnership Outreach Program Order Form (PDF)
  Please reach out to your Provider Relations Representative to order MHS brochures and other office items or fill out our online Materials Order Form.
• MemberConnections Referral Form (PDF)

Pharmacy

• Disease/Drug Specific Prior Authorization Forms
• General Specialty Prior Authorization Form (PDF)
• Medication Prior Authorization Form (PDF)
• 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 and Allwell Manuals & Forms

• Ambetter & Allwell Provider Enrollment Form (PDF)

For additional Ambetter information, please visit our Ambetter website.

For additional Allwell infomation, please visit our Allwell website.