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
- 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
- Hoosier Care Connect Forms
- Healthy Indiana Plan (HIP) Forms
- Hoosier Healthwise Forms
- Indiana PathWays for Aging 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
| Title | Version 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.
| Title | Version Date |
|---|
| Claims Attachment Cover Sheet | August 2024 |
| Consent for Sterilization – HHS-687 (07/25) |
| 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.
