The following forms, for use in the Indiana Health Coverage Programs (IHCP), are maintained by the Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) and its contractors, as well as other local and federal agencies. These forms are available in Adobe Acrobat portable document format (PDF) unless otherwise indicated. If you have trouble opening linked PDF files, view the PDF Help page.

Note: Many of these forms have been integrated into the IHCP Provider Healthcare Portal (IHCP Portal) and, therefore, are not required for transactions conducted via the IHCP Portal.

Forms are available in the following categories:

• 340B Program
• 590 Program
• Claim-Related Forms (Nonpharmacy)
• Claim Adjustment Forms (Nonpharmacy)
• Financial Forms
• Hospice Forms
• Hospital Forms
• Long-Term Care (LTC) Forms
• Managed Care Program Forms
  • Hoosier Care Connect Forms
  • Healthy Indiana Plan (HIP) Forms
  • Hoosier Healthwise Forms
  • Indiana PathWays for Aging Forms
• Medicaid Behavioral/Physical Health Coordination
• Medical Clearance Forms and Certifications of Medical Necessity
• Pharmacy Forms
• Prior Authorization (Nonpharmacy)
• Provider Correspondence Forms
• Provider Enrollment Forms
• Self-Disclosure of Provider Overpayments
• Third-Party Liability (TPL) Forms

340B Program

590 Program

Claim-Related Forms (Nonpharmacy)

The following forms may be required in conjunction with a claim. Providers can order CMS-1500 (professional), ADA 2012 (dental) and UB-04 (institutional) claim forms from a standard form supply company.

Claim Adjustment Forms (Nonpharmacy)

Financial Forms

Hospice Forms

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

Hospital Forms

Long-Term Care (LTC) Forms

Managed Care Program Forms

Healthy Indiana Plan (HIP) Forms

Hoosier Care Connect Forms

Hoosier Healthwise Forms

Indiana PathWays for Aging Forms

Medicaid Behavioral/Physical Health Coordination

Medical Clearance Forms and Certifications of Medical Necessity

Pharmacy Forms

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

Prior Authorization (Nonpharmacy)

Note: For forms related to HIP fast track and full eligibility notification, see the Healthy Indiana Plan (HIP) Forms section.

Provider Correspondence Forms

The forms in this section are specific to fee-for-service (FFS), nonpharmacy transactions, and are not appropriate for inquiries or administrative review requests related to prior authorization.

Provider Enrollment Forms

See the IHCP Provider Enrollment and Maintenance Actions page and the Update Your Provider Profile page for provider enrollment forms.

To enroll as a managed care provider, see Enrolling as a Managed Care Program Provider.

Self-Disclosure of Provider Overpayments

See the Protocol for Voluntary Self-Disclosure of Provider Overpayments page for more information about using the following forms.

Third-Party Liability (TPL) Forms