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 to disenroll:

  • 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

Note

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 form.
  • 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

  1. 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 mailing.
  2. Make a copy of the form for your records.
  3. Mail the form to Hewlett Packard Enterprise at the following address:
    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 disenrollment form.

  • 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 receive notification.