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
- 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
| Title | Version 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
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)
| Title | Version 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
| Title | Version 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.
| Title | Version 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
Long-Term Care (LTC) Forms
| Title | Version 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
| Title | Version 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
| Title | Version 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
| Title | Version 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
| Title | Version 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
| Title | Version 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
| Title | Version Date |
|---|---|
| Augmentative Communication System Selection Form | May 2022 |
| January 2023 | |
| 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)
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.
| Title | Version 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.
| Title | Version 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
| Title | Version 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 |