Forms
NOTE: If you have trouble opening linked PDF files,
please view the PDF Help
page.
The following forms are available in Adobe Acrobat portable
document format (pdf) unless otherwise indicated. If you do not
already have Acrobat, please see the Web Toolkit. Files indicated as being
available in MS Word can be saved to your PC by right-clicking on
the link and choosing the "Save Target As"
option.
Forms are available in the following categories:
590 Program
| Description |
|
|
Revision Date |
| 590 Program Enrollment/Discharge/Transfer (EDT) State Form
32696 (R_____) / OMPP 0747 |
Acrobat |
|
October 2006 |
| Provider Authorization (590 Program Membership Information for
Outside the 590 Program Facility) |
Link |
|
July 2010 |
| FSSA OMPP 590 Program Facilities Agreement |
Acrobat |
Word |
January 2012
|
ACA
Physician Self-Attestation Form for Increased Reimbursement for
Primary Care Services
| Description |
|
Revision Date |
| ACA Physician Self-Attestation Form for Increased Reimbursement
for Primary Care Services |
Acrobat |
December 2012
|
Care select
| Description |
|
|
Revision Date |
Care Select Provider Referral
Form
|
Acrobat |
Word |
June 2011 |
| State Psychiatric Hospital Care Select Disenrollment/Enrollment
Form |
Acrobat |
Word |
January 2008 |
Claims Forms (NonPharmacy)
| Description |
|
|
Revision Date |
| Attachment Cover Sheet |
Acrobat |
Word |
March 2011 |
Claim Certification Statement for Signature on File
|
Acrobat |
|
March 2012
|
HHS-687 (05/10) - Consent for Sterilization (English)
|
Acrobat |
|
Expires October 31, 2015 |
HHS-687-1 (11/06) - Consent for Sterilization (Spanish)
|
Acrobat |
|
Expires October 31, 2015 |
Claim
Adjustment Forms (NonPharmacy)
| Description |
|
|
Revision Date |
| CMS-1500, Dental, Crossover Part B Paid Claim Adjustment
Request Form |
Acrobat |
Word |
March 2011 |
| UB-04 and Inpatient/Outpatient Crossover Adjustment Request
Form |
Acrobat |
Word |
August 2010 |
CPS Request for
Settlement
| Description |
|
Revision Date |
| CPS Request for Settlement Form |
Acrobat |
December 2009
|
EDI Solutions forms
| Description |
|
Revision Date |
EDI 270 Eligibility Request Form
|
Acrobat |
January 2012
|
| EDI 835 Remittance Advice Request Form |
Acrobat |
January 2012 |
Financial
Forms
| Description |
|
Revision Date |
Electronic Funds Transfer (EFT) Form within the Provider Update
Form
|
Acrobat
|
March 2012
|
| IRS W-9 Form |
Link |
N/A
|
Hospice
Forms
See the Hospice Forms page for descriptions
of all hospice forms.
| Description |
|
Revision Date |
| Change in Status of Medicaid Hospice Patient Form |
Acrobat |
April 1998 |
| Hospice Accounts Receivable Refund Adjustment Form |
Acrobat |
July 2011 |
| Hospice Authorization Notice for Dually Eligible
Medicare/Medicaid Nursing Facility Residents Form |
Acrobat |
March 2003 |
| Hospice Provider Change Request Between Indiana Hospice
Providers Form |
Acrobat |
December 2002 |
| Medicaid Hospice Discharge Form |
Acrobat |
December 2002 |
| Medicaid Hospice Election Form |
Acrobat |
February 2012 |
| Medicaid Hospice Physician Certification Form |
Acrobat |
December 2002 |
| Medicaid Hospice Plan of Care Form |
Acrobat |
February 2009 |
| Medicaid Hospice Plan of Care for Curative Care - Members 20
Years and Younger |
Acrobat |
February 2012
|
| Medicaid Hospice Revocation Form |
Acrobat |
April 1998 |
Long Term Care (LTC)
Forms
| Description |
|
|
Revision Date |
| Certification Statement by Medicaid-Enrolled Nursing
Facilities |
Link |
|
August 2011
|
| Long Term Care (LTC) Nursing Home Administrators FAX Procedures
to obtain PDP information for multiple residents |
Acrobat |
Word |
December 2005 |
| Nursing Facility Level of Service State Authorization and Data
Entry Form |
Acrobat |
|
November 1998 |
| Physician Certification for Long-Term Care Services Form |
Acrobat |
|
June 1993 |
Medicaid
Behavioral/Physical Health Coordination
| Description |
|
Revision Date |
| Medicaid Behavioral/Physical Health Coordination Form |
Acrobat |
November 2004 |
Medical
Clearance Forms and Certifications of Medical
Necessity
| Description |
|
Revision Date |
| Augmentative Communication System Selection Form |
Acrobat |
September 2004 |
| Certification of Medical Necessity: Oxygen |
Acrobat |
September 2004 |
| Certification of Medical Necessity: Parenteral and Enteral
Nutrition |
Acrobat |
September 2004 |
| Medicaid Second Opinion Form |
Acrobat |
September 2004 |
| Medical Clearance Form for Hearing Aids |
Acrobat |
September 2004 |
| Medical Clearance Form for Hospital Beds |
Acrobat |
September 2004 |
| Medical Clearance Form for Motorized Wheelchair Purchase |
Acrobat |
September 2004 |
| Medical Clearance Form for Negative Pressure Wound Therapy |
Acrobat |
September 2004 |
| Medical Clearance Form for Non-Motorized Wheelchair
Purchase |
Acrobat |
September 2004 |
| Medical Clearance Form for Standers |
Acrobat |
September 2004 |
| Medical Clearance Form for TENS Unit |
Acrobat |
September 2004 |
National Provider Identifier
(NPI) Forms
| Description |
|
|
Revision Date |
| NPI Reporting Form |
Acrobat |
Word |
March 2007 |
Pharmacy
Forms
| Description |
|
|
Revision Date |
Anti-Ulcer Medications (Carafate and Cytotec) PA Form
|
Acrobat |
Word |
May 2012 |
| Brand Medically Necessary Prior Authorization Request Form |
Acrobat |
Word |
May 2012 |
Daliresp Prior Authorization Request Form (effective July 1,
2012, and after)
|
Acrobat |
Word |
June 2012 |
| Dificid Prior Authorization Request Form (effective July 1,
2012) |
Acrobat |
Word |
June 2012 |
| Forteo Prior Authorization Request Form |
Acrobat |
Word |
May 2012 |
| FSSA: Manufacturer PDL Submission Application, Checklist,
Notice of Intention, Manufacturer Responsibilities, and
Timeline |
Acrobat |
Word |
April 2010 |
Growth Hormone PA Form for Age Less Than 18
|
Acrobat |
Word |
June 2012 |
| Growth Hormone PA Form for Age Greater Than or Equal to 18 |
Acrobat |
Word |
May 2012 |
| IHCP Early Refill Prior Authorization Request Form |
Acrobat |
Word |
May 2012 |
| Incivek/Victrelis Prior Authorization Request Form |
Acrobat |
Word |
May 2012 |
| Indiana Medicaid Compound Prescription Claim Form (Version D.0
form) |
Acrobat |
Word |
January 2012 |
| Indiana Medicaid Pharmacy Claims Attachment Cover Sheet |
Acrobat |
Word |
April 2010 |
| Indiana Medicaid Drug Claim Form (NCPDP Pharmacy Paper Claim
Form) (Version D.0 form)
|
Acrobat |
Word |
January 2012 |
| Mental Health Quality Advisory Committee (MHQAC) Medical
Necessity Review/PA Form |
Acrobat |
Word |
May 2012 |
| PBM Call Center LTC ProDUR and Home Health Prior Authorization
Request Form |
Acrobat |
Word |
May 2012 |
| PBM Call Center Prior Authorization Request Form |
Acrobat |
Word |
May 2012 |
| Pharmacy Paid Claim Adjustment Request Form |
Acrobat |
Word |
Apri 2010 |
| Pharmacy Billing Instructions (Version D.0 instructions) |
Acrobat |
Word |
January 2012
|
| POS Reversal Void Request Form |
Acrobat |
Word |
April 2010 |
| Suboxone/Subutex Initiation Prior Authorization Form |
Acrobat |
Word |
May 2012 |
| Suboxone Renewal Prior Authorization Form |
Acrobat |
Word |
May 2012 |
Synagis Prior Authorization Form
|
Acrobat |
Word |
May 2012 |
Prior
Authorization
| Description |
|
|
Revision Date |
| Prior Authorization - System Update Request Form |
Acrobat |
Word |
October 2007 |
| Prior Review and Authorization Dental Request Form |
Acrobat |
Word |
October 2007 |
| Medicaid Appeal Request Form |
Acrobat |
Word |
July 2012
|
Universal Prior Authorization Request Form
|
Acrobat |
Word |
January 2011
|
Universal Prior Authorization Request Form - Instructions
|
Acrobat |
|
October 2010
|
| Psychiatric Residential Treatment Facility (PRTF) Admission
Assessment |
Acrobat |
|
May 2013 |
| Psychiatric Residential Treatment Facility (PRTF) Extension
Request Tool |
Acrobat |
|
May 2013 |
Provider Correspondence
Forms
| Description |
|
|
Revision Date |
Indiana Health Coverage Programs Forms Request
|
Acrobat |
Word |
August 2011
|
Indiana Health Coverage Programs Inquiry - for submitting a
written inquiry
|
Acrobat |
Word |
July 2011 |
| Policy Consideration Form |
Acrobat |
Word |
June 2011 |
Provider Enrollment Forms
See the Provider Enrollment page for all
Provider Enrollment forms.
Third Party Liability (TPL)
Forms
| Description |
|
|
Revision Date |
| Credit Balance Worksheet |
Acrobat |
Word |
May 2005 |
| Credit Balance Worksheet Instructions |
Acrobat |
Word |
January 2005 |
| Medicaid Third Party Accident/Injury Questionnaire |
Acrobat |
Word |
August 2011
|
| Medicaid Third Party Liability Questionnaire |
Acrobat |
Word |
August 2011 |
| Provider TPL Referral Form |
Acrobat |
Word |
August 2011 |
| Request for Medicaid Pregnancy and Birth Expenditures |
Acrobat |
Word |
August 2011 |