Forms
All files are available as Adobe Acrobat PDF unless otherwise stated.
Provider Enrollment
- Non Contracted Provider Set-Up Form,
You can also use the online form - Billing Address Update Form
- Hoosier Healthwise, Healthy Indiana Plan
and Hoosier Care Connect Provider Enrollment Form - Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Hospital and Ancillary Credentialing Form
Claims
Prior Authorization
- IHCP Prior Authorization Form - Please call in prior authorization requests for prompt service.
- Prior Authorization Provider Handout
Pay for Performance
Care Management
- Adult Health Maintenance Form
- Behavioral/Physical Health Coordination Form
- Diabetic Flowsheet
- MemberConnections® Referral Form
- Care/Case/Disease Management Request
- Indiana’s Tobacco Quitline Consent Form
EPSDT Templates
- Newborn
- 1-2 Months
- 3-4 Months
- 5-6 Months
- 7-9 Months
- 10-12 Months
- 15 Months
- 18 Months
- 24 Months
- 30 Months
- 3-4 Years
- 5-6 Years
- 7-10 Years
- 11-14 Years
- 15-21 Years
- Well-Child Documentation Tips
Member Management
- Full Panel Add Request Form
- In-Office PMP Change Request
- Member Disenrollment Form
- Hold Panel Add Request Form
- PMP Selection & Pre-Birth Selection Form
- Outreach Items Request Form
Please reach out to your Provider Relations Representative to order MHS brochures and other office items. - Community Partner Request Form
Pharmacy
- Medication Prior Authorization Form
- General Specialty Prior Authorization Form
- 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.