Forms

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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" 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 Program Addendum to the PMP Agreement Acrobat October 2007
Indiana Care Select Disease Management Program Provider Referral Form                         
Acrobat Word June 2011

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

Financial Forms

Description
Revision Date
Electronic Funds Transfer (EFT) Form within the Provider Update Form
Acrobat
January 2014
IRS W-9 Form Link N/A

Healthy Indiana Plan Forms

Description
Revision Date
Report of Change in Child/Family Status Acrobat November 2007
Find Anthem - Healthy Indiana Plan forms at anthem.com Link N/A
Find MDwise - Healthy Indiana Plan forms at mdwise.org Link N/A
Find Managed Health Services - Healthy Indiana Plan forms at mhsindiana.com Link
N/A

Hoosier healthwise Forms

Description
Revision Date
Find Anthem - Hoosier Healthwise forms at anthem.com Link N/A
Find MDwise - Hoosier Healthwise forms at mdwise.org
Link N/A
Find Managed Health Services - Hoosier Healthwise forms at
mhsindiana.com
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 January 2014
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

For all pharmacy-related forms, refer to the Pharmacy Services quick link on this website.

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

Indiana Health Coverage Programs Prior Authorization Request Form (universal PA form)

Acrobat

Word

November 2013

Indiana Health Coverage Programs Prior Authorization Request Form - Instructions (universal PA form - instructions)

Acrobat

Word

November 2013

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 Written Inquiry Form 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