Indiana Health Coverage Programs

Forms

The following forms are available in Adobe Acrobat portable document format (pdf) unless otherwise indicated. If you do not already have Acrobat, please see the Web Tool Kit. Files indicated as being available in MS Word can be saved to your PC by right-clicking on the link and choosing the "Save Target As" option.

590 Program			Updated
590 Program Enrollment/Discharge/Transfer (EDT) State Form 32696 (R_____) / OMPP 0747	Acrobat		October, 2006
590 Program Membership Information for Outside the 590 Program Facility, State Form 15899 (R3/6-96)	Acrobat	Word	October, 2006
IFSSA OMPP 590 Program Facilities Agreement	Acrobat	Word	October, 2006
State Psychiatric Hospital Care Select Disenrollment Link	Acrobat	Word	January, 2008

Claim Forms (Non-Pharmacy)			Updated
Attachment Cover Sheet	Acrobat	Word	February, 2008
Care Coordination Outcome Report Form	Acrobat		April, 2002
Claim Certification Statement for Signature on File	Acrobat		October, 2004
Combined Initial Reassessment Prenatal Form (CIRPNCCAF)	Acrobat		March, 2006
Combined Inital Reassessment Prenatal Form (CIRPNCCAF) Form Locator	Acrobat		March, 2006
Postpartum Assessment Form (PPAF)	Acrobat		March, 2006
Postpartum Assessment Form (PPAF) Form Locator	Acrobat		March, 2006
Prenatal Risk Assessment Form	Acrobat		March, 2006
State Form 46314 (10/93) - Consent to Sterilization (English)	Link		December, 2006
State Form 46314 (10/93) - Consent to Sterilization (Spanish)	Link		December, 2006

Claim Adjustment Forms (Non-Pharmacy)			Updated
CMS 1500, Dental, Crossover Part B Paid Claim Adjustment Request Form	Acrobat	Word	February, 2008
UB-04 and Inpatient/Outpatient Crossover Adjustment Request Form	Acrobat	Word	February, 2008

CPS Request for Settlement			Updated
CPS Request for Settlement Form	Acrobat		September, 2007

EDI Outbound Transactions Request			Updated
EDI Outbound Transactions Request	Acrobat	Word	March, 2007

Financial Forms			Updated
Electronic Funds Transfer (EFT) Form within the Provider Update Form		Word	October, 2007
IRS W-9 Form	Acrobat

Hospice Forms			Updated
IHCP Hospice Provider Services	Link

Long Term Care (LTC) Forms			Updated
Long Term Care (LTC) Nursing Home Administrators FAX Procedures to obtain PDP information for multiple residents	Acrobat	Word	December, 2005

Medicaid Behavioral/Physical Health Coordination			Updated
Medicaid Behavioral/Physical Health Coordination Form	Acrobat	Input Form	November, 2004

Medical Clearance Forms and Certifications of Medical Necessity			Updated
Augmentative Communication System Selection Form	Acrobat		September, 2004
Certification of Medical Necessity: Oxygen	Acrobat		September, 2004
Certification of Medical Necessity: Parenteral and Enteral Nutrition	Acrobat		September, 2004
Medicaid Second Opinion Form	Acrobat		September, 2004
Medical Clearance and Audiometric Test Form	Acrobat		September, 2004
Medical Clearance Form for Hearing Aids	Acrobat		September, 2004
Medical Clearance Form for Hospital Beds	Acrobat		September, 2004
Medical Clearance Form for Motorized Wheelchair Purchase	Acrobat		September, 2004
Medical Clearance Form for Negative Pressure Wound Therapy	Acrobat		September, 2004
Medical Clearance Form for Non-Motorized Wheelchair Purchase	Acrobat		September, 2004
Medical Clearance Form for Standers	Acrobat		September, 2004
Medical Clearance Form for TENS Unit	Acrobat		September, 2004

National Provider Identifier (NPI) Forms			Updated
NPI Reporting Form	Acrobat	Word	March, 2007

Pharmacy Forms			Updated
COX-2 Inhibitor, Arthrotec, and Brand Name NSAID Authorization Request Form	Acrobat	Word	April, 2009
Forteo Prior Authorization Request Form	Acrobat	Word	April, 2009
FSSA: Manufacturer PDL Submission Application, Checklist, Notice of Intention, Manufacturer Responsibilities, and Timeline	Acrobat	Word	March, 2006
Growth Hormone PA Form for Age Less Than 18	Acrobat	Word	May, 2009
Growth Hormone PA Form for Age Greater Than or Equal To 18	Acrobat	Word	May, 2009
Indiana Medicaid Compound Prescription Claim Form	Acrobat	Word	obsolete after May 22, 2008
Indiana Medicaid Compound Prescription Claim Form	Acrobat	Word	effective May 23, 2008
Indiana Medicaid Pharmacy Claims Attachment Cover Sheet	Acrobat	Word	September, 2005
Indiana Medicaid Drug Claim Form (NCPDP Pharmacy Paper Claim Form)	Acrobat	Word	obsolete after May 22, 2008
Indiana Medicaid Drug Claim Form (NCPDP Pharmacy Paper Claim Form)	Acrobat	Word	effective May 23, 2008
Manufacturer Preferred Drug List Submission Application	Acrobat		March, 2005
Mental Health Prior Authorization Form	Acrobat	Word	April, 2009
PBM Call Center LTC ProDUR Prior Authorization Request Form	Acrobat	Word	April, 2009
PBM Call Center Prior Authorization Request Form	Acrobat	Word	April, 2009
Pharmacy Paid Claim Adjustment Request Form	Acrobat	Word	May, 2008
Pharmacy Billing Instructions	Acrobat	Word	obsolete after May 22, 2008
Pharmacy Billing Instructions	Acrobat	Word	effective May 23, 2008
POS Reversal Void Request Form	Acrobat	Word	May, 2008
Prudent Rx Pharmacy Information Fax Form	Acrobat		Obsolete after May 22, 2008
Prudent Rx Pharmacy Information Fax Form	Acrobat		effective May 23, 2008
Synagis Prior Authorization Form	Acrobat	Word	April, 2009

Prior Authorization			Updated
Prior Authorization - System Update Request Form	Acrobat	Word	October, 2007
Prior Review and Authorization Dental Request Form	Acrobat	Word	October, 2007
Prior Review and Authorization Request Form	Acrobat	Word	October, 2007

Provider Correspondence Forms			Updated
Certification Statement by Medicaid-Enrolled Nursing Facilities	Acrobat		October, 2002
For paper copies of non-Pharmacy forms, complete a Forms Request	Acrobat	Word	March, 2003
Indiana Health Coverage Programs Inquiry - for submitting a written inquiry on non-Pharmacy issues	Acrobat	Word	January, 2002

Provider Enrollment Forms			Updated
See the Provider Enrollment page for all Provider Enrollment forms	Link		October, 2007

Third Party Liability (TPL) Forms			Updated
Credit Balance Worksheet	Acrobat	Word	May, 2005
Credit Balance Worksheet Instructions	Acrobat	Word	January, 2005
Medicaid Third Party Accident/Injury Questionnaire	Acrobat	Word	October, 2007
Medicaid Third Party Liability Questionnaire	Acrobat	Word	March, 2002
Provider TPL Referral Form	Acrobat	Word	March, 2005
Request for Medicaid Pregnancy and Birth Expenditures	Acrobat	Word	October, 2004