Disenroll from the IHCP
Providers may voluntarily disenroll from the Indiana Health
Coverage Programs (IHCP) using the IHCP
Provider Disenrollment Form on the Update Your
Provider Profile page of this website. This form may be used
- An entire group or billing provider enrollment
- A specific service location
- Rendering provider linkages from a provider group or from one
or more service locations
- Waiver rendering provider linkages from a waiver provider group
or from one or more service locations
Providers that want to disenroll from the IHCP should keep the
following in mind:
- Providers enrolled as primary medical providers (PMPs) with a
managed care entity (MCE) must contact the MCE to begin the
disenrollment process before submitting this
- Waiver providers must contact the waiver divisions at the State
before submitting this form.
- Ordering, prescribing, or referring (OPR) providers who want to
disenroll should see Participating as an
OPR Provider on this website.
Basic Steps to Disenroll
- Complete the IHCP
Provider Disenrollment Form.
- Detailed instructions are included in the form.
- Be sure to get appropriate signatures.
- The disenrollment form is an interactive PDF file, allowing you
to type information into the fields from your computer, save the
completed file to your computer, and print the file for
- Make a copy of the form for your records.
- Mail the form to Hewlett Packard Enterprise at the following
Provider Enrollment Unit
P.O. Box 7263
Indianapolis, IN 46207-7263
Processing Your Disenrollment
Please allow at least 20 business days for mailing and
processing before checking the status of your disenrollment. You
will be notified after the Provider Enrollment Unit processes your
- If the packet needs correcting or is missing required
documentation, the Provider Enrollment Unit will contact you by
telephone, email, fax, or mail. This contact is intended to
communicate what needs to be corrected, completed, and submitted
before the IHCP can process your enrollment transaction. If an
application is rejected for missing or incomplete information, the
entire packet will be returned to the provider with a letter
indicating what needs to be corrected or attached. Providers MUST
return the entire packet, as well as a copy of the provider letter,
when submitting the correction or missing information.
- If the form is complete, it will be processed, and you will