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 Growth Hormone PA Form for Age Less Than 18 Acrobat Word March, 2008 Growth Hormone PA Form for Age Greater Than or Equal To 18 Acrobat Word March, 2008 COX-2 Inhibitor, Arthrotec, and Brand Name NSAID Authorization Request Form Acrobat Word March, 2008 FSSA: Manufacturer PDL Submission Application, Checklist, Notice of Intention, Manufacturer Responsibilities, and Timeline Acrobat Word March, 2006 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 January, 2008 PBM Call Center LTC ProDUR Prior Authorization Request Form Acrobat Word March, 2008 PBM Call Center Prior Authorization Request Form Acrobat Word March, 2008 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 Prudent Rx Pharmacy Information Fax Form Acrobat Obsolete after May 22, 2008 Prudent Rx Pharmacy Information Fax Form Acrobat effective May 23, 2008 POS Reversal Void Request Form Acrobat Word May, 2008 Synagis Prior Authorization Form Acrobat Word March, 2008   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     Banner List Bulletin List Fee Schedule Forms IHCP Email Notifications LTC DME Per Diem Manuals Newsletters Preferred Drug Listing Provider Code Sets State Plan Take the Provider Survey