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Billing Provider Enrollment Process |
To enroll as a billing provider in IHCP, please complete all the required forms as described in this process. The
Billing Provider Enrollment Application Instructions and
Attachment B - Provider Specialty Requirements describe which forms are
required according to the provider specialty type. Submit the required forms along with all necessary certifications
and licensure requirements as outlined in this process. The following forms may be required depending on the requirements outlined in
Attachment B - Provider Specialty Requirements.
Print complete Billing Provider Enrollment Packet at once. - Last updated October, 2003
Billing Provider Enrollment Application - Last updated February, 2003
Billing Provider Agreement - Last updated February, 2003
Outpatient Mental Health Addendum - Last updated April, 2002
Billing Provider Specialty List This reference information will help you determine which provider specialty to use on your application. This is not a form that needs to be completed.
W-9 Form tax identification
W-9 Attachment Form - Last updated April, 2002
Change of Ownership form - Last updated April, 2002
Provider Signature Certification form - Last updated April, 2002
Before you send your application, read the
Enrollment Application Checklist to ensure you avoid the most common mistakes made when submitting provider enrollment applications.
To have your IHCP payment electronically transferred to your bank, please complete the
Electronic Funds Transfer (EFT) form. - Last updated April, 2002
Thank you for your application! You will receive notification by mail when your application has been processed.
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