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Forms

The following 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.

Forms are available in the following categories:


590 Program

TitleVersion Date
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)External link
FSSA OMPP 590 Program Facilities AgreementApril 2017

Claim Forms (Nonpharmacy)

TitleVersion Date
Claims Attachment Cover SheetFebruary 2021
Claim Certification Statement for Signature on FileJune 2012
HHS-687 (04/22) - Consent for Sterilization (English)External link
HHS-687-1 (04/2022) - Consent for Sterilization (Spanish)External link
IHCP Third-Party Liability (TPL)/Medicare Special Attachment FormOctober 2016
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form InstructionsAugust 2017

Claim Adjustment Forms (Nonpharmacy)

TitleVersion Date
IHCP Professional, Dental, or Medicare Part B Crossover Claim Adjustment RequestFebruary 2021
IHCP Institutional and Inpatient/Outpatient Crossover Adjustment RequestFebruary 2021

CPS Request for Settlement

TitleVersion Date
CPS Request for Settlement FormDecember 2009

Financial Forms

TitleVersion Date
IHCP Electronic Funds Transfer Addendum/Maintenance FormAugust 2017
IRS W-9 FormExternal link

Healthy Indiana Plan Forms

TitleVersion Date
Report of Change in Child/Family StatusNovember 2007
Find Anthem - Healthy Indiana Plan forms at anthem.comExternal link
Find CareSource Indiana - Healthy Indiana Plan forms at caresource.comExternal link
Find MDwise - Healthy Indiana Plan forms at mdwise.orgExternal link
Find Managed Health Services - Healthy Indiana Plan forms at mhsindiana.comExternal link

Hoosier Care Connect Forms

TitleVersion Date
Find Anthem - Hoosier Care Connect forms at anthem.comExternal link
Find Managed Health Services - Hoosier Care Connect forms at mhsindiana.comExternal link
Find UnitedHealthcare - Hoosier Care Connect forms at uhcprovider.comExternal link

Hoosier Healthwise Forms

TitleVersion Date
Find Anthem - Hoosier Healthwise forms at anthem.comExternal link
Find CareSource Indiana - Hoosier Healthwise forms at caresource.comExternal link
Find MDwise - Hoosier Healthwise forms at mdwise.orgExternal 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 FormApril 1998
Hospice Accounts Receivable Refund Adjustment FormFebruary 2021
Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents FormMarch 2003
Hospice Provider Change Request Between Indiana Hospice Providers FormDecember 2002
Medicaid Hospice Discharge FormDecember 2002
Medicaid Hospice Election Form

Elección Del Hospital (Medicaid Hospice Election Form - Spanish version)
January 2012

August 2015
Medicaid Hospice Physician Certification FormDecember 2002
Medicaid Hospice Plan of Care FormFebruary 2009
Medicaid Hospice Plan of Care for Curative Care - Members 20 Years and YoungerFebruary 2012
Medicaid Hospice Revocation FormApril 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

Long-Term Care (LTC) Forms

TitleVersion Date
Certification Statement by Medicaid-Enrolled Nursing FacilitiesExternal link
Long Term Care (LTC) Nursing Home Administrators FAX Procedures to obtain PDP information for multiple residentsDecember 2005

Medicaid Behavioral/Physical Health Coordination

TitleVersion Date
Medicaid Behavioral/Physical Health Coordination FormExternal link

Medical Clearance Forms and Certifications of Medical Necessity

TitleVersion Date
Augmentative Communication System Selection FormSeptember 2004
Certification of Medical Necessity: OxygenExternal link
Certification of Medical Necessity: Parenteral and Enteral NutritionExternal link
Medicaid Second Opinion FormAugust 2014
Medical Clearance and Audiometric Test Form (the medical clearance form for hearing aids)October 2014
Medical Clearance Form for Hospital and Specialty BedsJune 2014
Medical Clearance Form for Motorized Wheelchair PurchaseOctober 2014
Medical Clearance Form for Negative Pressure Wound TherapyJuly 2014
Medical Clearance Form for Nonmotorized Wheelchair PurchaseFebruary 2015
Medical Clearance Form for Standing EquipmentMarch 2015
Medical Clearance Form for TENS UnitOctober 2014

Pharmacy Forms

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


Prior Authorization

TitleVersion Date
IHCP Applied Behavioral Analysis (ABA) Prior Authorization ChecklistJuly 2018
IHCP Fast Track Notification FormFebruary 2019
IHCP Full Eligibility Notification FormFebruary 2019
IHCP Prior Authorization Request Form (universal PA form)May 2021
IHCP Prior Authorization Request Form Instructions
(universal PA form - instructions)
March 2021
IHCP Dental Prior Authorization Request FormJanuary 2020
IHCP Dental Prior Authorization Request Form InstructionsJanuary 2020
IHCP Prior Authorization - System Update Request FormNovember 2017
IHCP Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request FormMay 2021
IHCP Initial Assessment Form for Substance Use Disorder (SUD) Treatment AdmissionFebruary 2019
IHCP Reassessment Form for Continued Substance Use Disorder (SUD) TreatmentFebruary 2019
Psychiatric Residential Treatment Facility (PRTF) Admission AssessmentMay 2013
Psychiatric Residential Treatment Facility (PRTF) Extension Request ToolMay 2013

Provider Correspondence Forms

TitleVersion Date
Indiana Health Coverage Programs Written Inquiry FormFebruary 2021
Indiana Health Coverage Programs Administrative Review RequestFebruary 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 WorksheetMay 2005
Credit Balance Worksheet InstructionsJanuary 2005
IHCP Third-Party Liability (TPL)/Medicare Special Attachment FormOctober 2016
IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form InstructionsAugust 2017
Medicaid Third-Party Liability Accident/Injury QuestionnaireSeptember 2019
Medicaid Third-Party Liability QuestionnaireApril 2021
Provider TPL Referral FormMarch 2018

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