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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:
Physician Self-Attestation Form for Increased Reimbursement for
Primary Care Services
Claims Forms (NonPharmacy)
Adjustment Forms (NonPharmacy)
CPS Request for
EDI Solutions forms
Healthy Indiana Plan
See the Hospice Forms page for descriptions
of all hospice forms.
Long Term Care (LTC)
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.
Provider Enrollment Forms
See the Provider Enrollment page for all
Provider Enrollment forms.
Third Party Liability (TPL)