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Forms

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

TitleVersion Date
Notice of 340B Program Participation Form for IHCP Managed Care Outpatient Drug Claims December 2023
Notice of 340B Program Cancellation Form for IHCP Managed Care Outpatient Drug Claims December 2023

590 Program

TitleVersion Date
Agreement Between 590 Facilities and the OMPP November 2023
Enrollment/Discharge/Transfer (EDT) State Hospitals and 590 Program – State Form 32696 (R3/2-16)/OMPP 0747 External link
Provider Authorization [590 Program membership information for outside the 590 Program facility] – State Form 15899 (R5/10-18)/OMPP 2021 External link

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.

TitleVersion Date
Claims Attachment Cover Sheet August 2024
Consent for Sterilization – HHS-687 (07/25)

Consentimiento para la esterilización (Consent for Sterilization – Spanish version) – HHS-687-1 (07/2025)
External link 
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form October 2016
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form Instructions August 2017

Claim Adjustment Forms (Nonpharmacy)

TitleVersion Date
IHCP Professional, Dental, or Medicare Part B Crossover Claim Adjustment Request August 2024
IHCP Institutional and Inpatient/Outpatient Crossover Adjustment Request August 2024

Financial Forms

TitleVersion Date
IHCP Electronic Funds Transfer Addendum/Maintenance Form May 2019
IRS W-9 Form External link

Hospice Forms

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

TitleVersion Date
Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents Form March 2003

Medicaid Hospice Election Form

Elección del hospital (Medicaid Hospice Election Form – Spanish version)

External Link

External Link

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
Hospice Provider Change Request Between Indiana Hospice Providers Form December 2002
Change in Status of Medicaid Hospice Patient Form April 1998
Medicaid Hospice Revocation Form April 1998
Medicaid Hospice Discharge Form December 2002

Hospital Forms

TitleVersion Date
Enrollment/Discharge/Transfer (EDT) State Hospital and 590 Program (State Form 32696 (R3/2-16)/OMPP 0747) External link
Indiana Medicaid Hospital Request for Settlement: Suspect Child Abuse and Neglect Cases
(Department of Child Services [DCS]/Child Protective Services [CPS])
December 2009

Long-Term Care (LTC) Forms

TitleVersion Date
Certification Statement by Medicaid-Enrolled Nursing Facilities
That Are NOT Certified to Provide Medicare Part A Skilled Nursing Services
External link (Select Nursing Facility > Forms > Nursing Facility Cost Reports > Nursing Facility Cost Report – The certification statement is a worksheet of the cost report.)
Nursing Home Fax Procedures to Obtain Medicare Prescription Drug Plan Enrollment Information for Multiple Residents December 2005

Managed Care Program Forms

Healthy Indiana Plan (HIP) Forms

TitleVersion Date
Report of Change in Child/Family Status November 2007
IHCP Fast Track Notification Form February 2019
IHCP Full Eligibility Notification Form February 2019
Anthem – Healthy Indiana Plan forms at anthem.com External link
CareSource – Healthy Indiana Plan forms at caresource.com External link
MDwise – Healthy Indiana Plan forms at mdwise.org External link
Managed Health Services – Healthy Indiana Plan forms at mhsindiana.com External link

Hoosier Care Connect Forms

TitleVersion Date
Anthem – Hoosier Care Connect forms at anthem.com External link
Managed Health Services – Hoosier Care Connect forms at mhsindiana.com External link
UnitedHealthcare – Hoosier Care Connect forms at uhcprovider.com External link

Hoosier Healthwise Forms

TitleVersion Date
Anthem – Hoosier Healthwise forms at anthem.com External link
CareSource – Hoosier Healthwise forms at caresource.com External link
MDwise – Hoosier Healthwise forms at mdwise.org External link
Managed Health Services  – Hoosier Healthwise forms at mhsindiana.com External link

Indiana PathWays for Aging Forms

TitleVersion Date
Anthem – PathWays forms at anthem.com External link
Humana – PathWays forms at humana.com External link
UnitedHealthcare – PathWays forms at uhcprovider.com External link

Medicaid Behavioral/Physical Health Coordination

TitleVersion Date
Medicaid Behavioral/Physical Health Coordination Form – State Form 51856 (R2/12-04)/OMPP 0016 External link

Medical Clearance Forms and Certifications of Medical Necessity

TitleVersion Date
Augmentative Communication System Selection Form May 2022

Certificate of Medical Necessity for Oxygen

January 2023

DME Information Form for Enteral and Parenteral Nutrition

January 2023
Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial External link
Medicaid Second Opinion Form August 2014
Medical Clearance and Audiometric Test Form (the medical clearance form for hearing aids) October 2014
Medical Clearance Form for Hospital and Specialty Beds June 2014
Medical Clearance Form for Motorized Wheelchair Purchase October 2014
Medical Clearance Form for Negative Pressure Wound Therapy July 2014
Medical Clearance Form for Nonmotorized Wheelchair Purchase February 2015
Medical Clearance Form for Standing Equipment March 2015
Medical Clearance Form for TENS (Transcutaneous Electrical Nerve Stimulator) Unit October 2014

Pharmacy Forms

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


Prior Authorization (Nonpharmacy)

TitleVersion Date
Universal PA Request Form and Instructions
IHCP Prior Authorization Request Form (universal PA form) July 2024
IHCP Prior Authorization Request Form Instructions
(universal PA form - instructions)
July 2023
IHCP Prior Authorization Revision Request Form January 2024
Dental PA Request Form and Instructions
IHCP Dental Prior Authorization Request Form August 2022
IHCP Dental Prior Authorization Request Form Instructions August 2022
Residential/Inpatient SUD Treatment PA Request and Assessment Forms
IHCP Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form August 2024
IHCP Initial Assessment Form for Substance Use Disorder (SUD) Treatment Admission February 2019
IHCP Reassessment Form for Continued Substance Use Disorder (SUD) Treatment February 2019
Miscellaneous PA-Related Forms
Application for Emergency Detention of Mentally Ill & Dangerously or Gravely Disabled Person (State Form 52744) External link
Applied Behavioral Analysis (ABA) Prior Authorization Checklist July 2018
Psychiatric Residential Treatment Facility (PRTF) Admission Assessment May 2013
Psychiatric Residential Treatment Facility (PRTF) Extension Request Tool May 2013
Therapy Services Prior Authorization Checklist November 2022

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.

TitleVersion Date
Indiana Health Coverage Programs Written Inquiry Form August 2024
Indiana Health Coverage Programs Claim Administrative Review Request August 2024

Provider Enrollment Forms

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.


Self-Disclosure of Provider Overpayments

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

TitleVersion Date
Voluntary Self-Disclosure of Provider Overpayments Form August 2022
Voluntary Self-Disclosure of Provider Overpayments Form Instructions August 2022
Indiana Fraud and Abuse Detection System (FADS) Secure File Transfer Form August 2022
Indiana FADS Secure File Transfer Instructions August 2022

Third-Party Liability (TPL) Forms

TitleVersion Date
Credit Balance Worksheet May 2005
Credit Balance Worksheet Instructions January 2005
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form October 2016
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form Instructions August 2017
Medicaid Third-Party Liability Accident/Injury Questionnaire August 2024
Medicaid Third-Party Liability Questionnaire August 2024
Provider TPL Referral Form August 2024

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