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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 (Portal) and, therefore, are not required for transactions conducted via the Portal.

Forms are available in the following categories:


590 Program

TitleVersion Date
Agreement Between 590 Facilities and the OMPP April 2017
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 February 2021
Consent for Sterilization – HHS-687 (04/22)

Consentimiento para la esterilización (Consent for Sterilization – Spanish version) – HHS-687-1 (04/2022)
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 February 2021
IHCP Institutional and Inpatient/Outpatient Crossover Adjustment Request February 2021

Financial Forms

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

Healthy Indiana Plan (HIP) Forms

TitleVersion Date
Report of Change in Child/Family Status November 2007
IHCP Fast Track Notification FormFebruary 2019
IHCP Full Eligibility Notification FormFebruary 2019
Find Anthem – Healthy Indiana Plan forms at anthem.com External link
Find CareSource – Healthy Indiana Plan forms at caresource.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 Care Connect Forms

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

Hoosier Healthwise Forms

TitleVersion Date
Find Anthem – Hoosier Healthwise forms at anthem.com External link
Find CareSource – Hoosier Healthwise forms at caresource.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.

TitleVersion Date
Change in Status of Medicaid Hospice Patient Form April 1998
Hospice Accounts Receivable Refund Adjustment Form February 2021
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

Elección del hospital (Medicaid Hospice Election Form – Spanish version)
January 2012

August 2015
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

Hospital Forms

TitleVersion Date
Certification of the Need for Inpatient Psychiatric Hospital Services (State Form 44697 (R4/5-15)/OMPP 1261A) External link
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
Nursing Home Fax Procedures to Obtain Medicare Prescription Drug Plan Enrollment Information for Multiple Residents December 2005

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 FormMay 2022
Certification of Medical Necessity: CMS-484 – Oxygen External link
DME Information Form CMS-10126 – Enteral and Parenteral Nutrition 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) May 2021
IHCP Prior Authorization Request Form Instructions
(universal PA form - instructions)
March 2021
IHCP Prior Authorization - System Update Request Form November 2017
Dental PA Request Form and Instructions
IHCP Dental Prior Authorization Request Form January 2020
IHCP Dental Prior Authorization Request Form Instructions January 2020
Residential/Inpatient SUD Treatment PA Request and Assessment Forms
IHCP Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form May 2021
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
IHCP Applied Behavioral Analysis (ABA) Prior Authorization Checklist July 2018
IHCP Fast Track Notification Form [Healthy Indiana Plan] February 2019
IHCP Full Eligibility Notification Form [Healthy Indiana Plan] February 2019
Psychiatric Residential Treatment Facility (PRTF) Admission Assessment May 2013
Psychiatric Residential Treatment Facility (PRTF) Extension Request Tool May 2013

Provider Correspondence Forms

TitleVersion Date
Indiana Health Coverage Programs Written Inquiry Form February 2021
Indiana Health Coverage Programs Administrative Review Request February 2021

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.


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 QuestionnaireMarch 2022
Medicaid Third-Party Liability QuestionnaireMarch 2022
Provider TPL Referral Form March 2022

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