Forms
- Provider Enrollment
- Claims
- Prior Authorization
- Care Management
- Member Management
- Pharmacy
- Medical Record Fax Back Forms
- Provider Enrollment
- Non Par Set Up Form (PDF)
- PMP Disenrollment Form (PDF)
- Billing Address Update Form
- Claims
- Provider Claim Adjustment Request Form (PDF)
- Electronic Funds Transfer Form (PDF)
- Informal Claim Dispute or Objection Form (PDF)
- Prior Authorization
- Home Health Medical Clearance Forms (PDF)
- Referral Authorization Request Form (PDF)
- Provider Referral Request (PDF)
- Prior Authorization Form (PDF)
- Care Management
- Behavioral/Physical Health Coordination Form (PDF)
- Diabetic Flowsheet (PDF)
- Pregnancy Notification Form (PDF)
- Prenatal Vitamin Form (PDF)
- MemberConnections™ Referral Form (PDF)
- Member Management
- EPSDT Chart Forms (PDF)
- Full Panel Add Request Form (PDF)
- In-Office PMP Change Request (PDF)
- Member Disenrollment Form (PDF)
- Hold Panel Add Request Form (PDF)
- PMP Selection for Baby Prior to Birth (PDF)
- Pharmacy
- Pharmacy forms are now located on the Indiana Medicaid Web site:
Indiana Medicaid Pharmacy Forms - Medical Record Fax Back Forms
- Diabetic Care (PDF)
- Lead Screening (PDF)
- Mammogram (PDF)
- Cervical Cancer (PDF)
- Chlamydia (PDF)
- Immunization (Combo 2) (PDF)
- Well Visits (PDF)
To request a printed copy of one of these forms, please call Provider Services.
