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

Title Version Date
590 Program Enrollment/Discharge/Transfer (EDT) State Form 32696 (R_____) / OMPP 0747 October 2006
Provider Authorization (590 Program Membership Information for Outside the 590 Program Facility) July 2010
FSSA OMPP 590 Program Facilities Agreement January 2012

ACA Physician Self-Attestation Form for Increased Reimbursement for Primary Care Services

Title Version Date
ACA Physician Self-Attestation Form for Increased Reimbursement for Primary Care Services December 2012

Care select

Title Version Date
Care Select Program Addendum to the PMP Agreement October 2007
Indiana Care Select Disease Management Program Provider Referral Form
June 2011

Claims Forms (NonPharmacy)

Title Version Date
Attachment Cover Sheet March 2011
Claim Certification Statement for Signature on File
March 2012
HHS-687 (05/10) - Consent for Sterilization (English)
Expires October 31, 2015
HHS-687-1 (11/06) - Consent for Sterilization (Spanish)
Expires October 31, 2015

Claim Adjustment Forms (NonPharmacy)

Title Version Date
CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request Form March 2011
UB-04 and Inpatient/Outpatient Crossover Adjustment Request Form August 2010

CPS Request for Settlement

Title Version Date
CPS Request for Settlement Form December 2009

EDI Solutions forms

Title Version Date
EDI 270 Eligibility Request Form
January 2012

Financial Forms

Title Version Date
Electronic Funds Transfer (EFT) Form within the Provider Update Form
January 2014
IRS W-9 Form External Link

Healthy Indiana Plan Forms

Title Version Date
Report of Change in Child/Family Status November 2007
Find Anthem - Healthy Indiana Plan forms at anthem.com External Link
Find MDwise - Healthy Indiana Plan forms at mdwise.org External Link
Find Managed Health Services - Healthy Indiana Plan forms at mhsindiana.com External Link

Hoosier healthwise Forms

Title Version Date
Find Anthem - Hoosier Healthwise forms at anthem.com External Link
Find MDwise - Hoosier Healthwise forms at mdwise.org
External Link
Find Managed Health Services - Hoosier Healthwise forms at
mhsindiana.com

External Link

Hospice Forms

See the Hospice Forms page for descriptions of all hospice forms.

Title Version Date
Change in Status of Medicaid Hospice Patient Form April 1998
Hospice Accounts Receivable Refund Adjustment Form July 2011
Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents Form March 2003
Hospice Provider Change Request Between Indiana Hospice Providers Form December 2002
Medicaid Hospice Discharge Form December 2002
Medicaid Hospice Election Form February 2012
Medicaid Hospice Physician Certification Form December 2002
Medicaid Hospice Plan of Care Form February 2009
Medicaid Hospice Plan of Care for Curative Care - Members 20 Years and Younger February 2012
Medicaid Hospice Revocation Form April 1998

Long Term Care (LTC) Forms

Title Version Date
Certification Statement by Medicaid-Enrolled Nursing Facilities External Link
Long Term Care (LTC) Nursing Home Administrators FAX Procedures to obtain PDP information for multiple residents December 2005
Nursing Facility Level of Service State Authorization and Data Entry Form November 1998
Physician Certification for Long-Term Care Services Form June 1993

Medicaid Behavioral/Physical Health Coordination

Title Version Date
Medicaid Behavioral/Physical Health Coordination Form External Link

Medical Clearance Forms and Certifications of Medical Necessity

Title Version Date
Augmentative Communication System Selection Form September 2004
Certification of Medical Necessity: Oxygen External Link
Certification of Medical Necessity: Parenteral and Enteral Nutrition External Link
Medicaid Second Opinion Form August 2014
Medical Clearance Form for Hearing Aids September 2004
Medical Clearance Form for Hospital and Specialty Beds June 2014
Medical Clearance Form for Motorized Wheelchair Purchase January 2014
Medical Clearance Form for Negative Pressure Wound Therapy July 2014
Medical Clearance Form for Non-Motorized Wheelchair Purchase September 2004
Medical Clearance Form for Standers September 2004
Medical Clearance Form for TENS Unit October 2014

National Provider Identifier (NPI) Forms

Title Version Date
NPI Reporting Form March 2007

Pharmacy Forms

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

Prior Authorization

Title Version Date
Prior Authorization - System Update Request Form October 2007
Prior Review and Authorization Dental Request Form September 2014
Indiana Health Coverage Programs Prior Authorization Request Form (universal PA form) November 2013
Indiana Health Coverage Programs Prior Authorization Request Form - Instructions (universal PA form - instructions) November 2013
Psychiatric Residential Treatment Facility (PRTF) Admission Assessment May 2013
Psychiatric Residential Treatment Facility (PRTF) Extension Request Tool May 2013

Provider Correspondence Forms

Title Version Date
Indiana Health Coverage Programs Forms Request
August 2011
Indiana Health Coverage Programs Written Inquiry Form July 2011
Policy Consideration Form June 2011

Provider Enrollment Forms

See the IHCP Provider Enrollment Transactions page for all Provider Enrollment forms.

Third Party Liability (TPL) Forms

Title Version Date
Credit Balance Worksheet May 2005
Credit Balance Worksheet Instructions January 2005
Medicaid Third Party Accident/Injury Questionnaire August 2011
Medicaid Third Party Liability Questionnaire August 2011
Provider TPL Referral Form August 2011
Request for Medicaid Pregnancy and Birth Expenditures August 2011