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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"
Forms are available in the following categories:
Claims Forms (NonPharmacy)
Adjustment Forms (NonPharmacy)
CPS Request for
EDI Solutions forms
Healthy Indiana Plan
Hoosier Care Connect forms
See the Hospice Forms page for descriptions of
all hospice forms.
Term Care (LTC) Forms
Behavioral/Physical Health Coordination
Clearance Forms and Certifications of Medical
National Provider Identifier
For all pharmacy-related forms, refer to the Pharmacy
Services quick link on this website.
See the IHCP Provider
Enrollment Transactions page for provider enrollment forms.
To enroll as a managed care provider, see Enrolling as
a Managed Care Program Provider.
Third Party Liability (TPL)