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

• Informal Claim Dispute or Objection Form

Prior Authorization

• IHCP Prior Authorization Form - Please call in prior authorization requests for prompt service.
• Prior Authorization Provider Handout

Pay for Performance

• Faxback Form

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.