Indiana Health Coverage Programs (IHCP) Managed Care Entity (MCE) Provider Enrollment Form Instructions
This form contains 297 fields organized into 48 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Accessibility Accommodations | ||
| Building - Yes | RadioButton |
Check this box if the site offers accessible building accommodations.
|
| Building - No | RadioButton |
Check this box if the site does not offer accessible building accommodations.
|
| Parking - Yes | RadioButton |
Check this box if the site offers accessible parking accommodations.
|
| Parking - No | RadioButton |
Check this box if the site does not offer accessible parking accommodations.
|
| Restroom - Yes | RadioButton |
Check this box if the site offers accessible restroom accommodations.
|
| Restroom - No | RadioButton |
Check this box if the site does not offer accessible restroom accommodations.
|
| Other Accessible Accommodations | Text |
Enter any additional accessible accommodations offered at this site that are not listed under Building, Parking, or Restroom.
|
| Age Restriction Categories | ||
| None | RadioButton |
Select if you do not apply any age restrictions to your patient panel. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 0–2 years | RadioButton |
Select if you restrict your patient panel to ages 0 through 2 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 0–12 years | RadioButton |
Select if you restrict your patient panel to ages 0 through 12 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 0–17 years | RadioButton |
Select if you restrict your patient panel to ages 0 through 17 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 0–20 years | RadioButton |
Select if you restrict your patient panel to ages 0 through 20 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 3+ years | RadioButton |
Select if you restrict your patient panel to ages 3 years and older. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 13+ years | RadioButton |
Select if you restrict your patient panel to ages 13 years and older. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 13–17 years | RadioButton |
Select if you restrict your patient panel to ages 13 through 17 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 13–20 years | RadioButton |
Select if you restrict your patient panel to ages 13 through 20 years. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 17+ years | RadioButton |
Select if you restrict your patient panel to ages 17 years and older. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 21+ years | RadioButton |
Select if you restrict your patient panel to ages 21 years and older. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| 65+ years | RadioButton |
Select if you restrict your patient panel to ages 65 years and older. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| Attestation Signature Block | ||
| Printed Name | Text |
Enter the practitioner’s full printed name to attest to the truthfulness and completeness of this application.
|
| Title | Text |
Enter the practitioner’s professional title or position as it should appear with the signature.
|
| Date | Date |
Enter the date on which the practitioner signed this attestation.
|
| Delivery Privileges | ||
| Delivery Privileges? Yes | RadioButton |
Check this box if you have delivery privileges to deliver obstetric (OB) services.
|
| Delivery Privileges? No | RadioButton |
Check this box if you do not have delivery privileges to deliver obstetric (OB) services.
|
| Delivery Privileges Hospital | Text |
Enter the name of the hospital where you have delivery privileges. Fill only if the 'Delivery Privileges?' is 'Yes'.
Depends on:
Delivery Privileges? Yes
|
| Delivery Privileges Address | Text |
Enter the address of the hospital where you have delivery privileges. Fill only if the 'Delivery Privileges?' is 'Yes'.
Depends on:
Delivery Privileges? Yes
|
| Delivery Relationship Privileges | ||
| Delivery Relationship Privileges: Yes | RadioButton |
Select this box if you do not have delivery privileges and you have relationship privileges for delivery. Fill only if the 'Delivery Privileges' is 'No'.
Depends on:
Delivery Privileges? No
|
| Delivery Relationship Privileges: No | RadioButton |
Select this box if you do not have delivery privileges and you do not have relationship privileges for delivery. Fill only if the 'Delivery Privileges' is 'No'.
Depends on:
Delivery Privileges? No
|
| Delivery Relationship Physician | Text |
Enter the name of the physician with whom you have delivery relationship privileges. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Delivery Relationship Hospital | Text |
Enter the name of the hospital where you have delivery relationship privileges. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Delivery Relationship Hospital Address | Text |
Enter the full address of the hospital where you have delivery relationship privileges, including street, city, state, and ZIP code. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Disability Services Offered | ||
| Text Telephony (TTY) – Yes | RadioButton |
Check this box if the site offers Text Telephony (TTY) services for people with disabilities.
|
| Text Telephony (TTY) – No | RadioButton |
Check this box if the site does not offer Text Telephony (TTY) services for people with disabilities.
|
| American Sign Language – Yes | RadioButton |
Check this box if the site offers American Sign Language services for people with disabilities.
|
| American Sign Language – No | RadioButton |
Check this box if the site does not offer American Sign Language services for people with disabilities.
|
| Mental/Physical Impairment Services – Yes | RadioButton |
Check this box if the site offers services for mental or physical impairments for people with disabilities.
|
| Mental/Physical Impairment Services – No | RadioButton |
Check this box if the site does not offer services for mental or physical impairments for people with disabilities.
|
| Other Disability Service | Text |
Enter any additional disability services offered at this site that are not listed above.
|
| Enrollment Role Selection | ||
| PMP with Panel | CheckBox |
Check this box if you are enrolling as a Primary Medical Provider (PMP) with a panel.
|
| Physician Specialist | CheckBox |
Check this box if you are enrolling as a Physician Specialist.
|
| NP Supporting a PMP | CheckBox |
Check this box if you are enrolling as a Nurse Practitioner supporting a Primary Medical Provider (PMP).
|
| Behavioral Health | CheckBox |
Check this box if you are enrolling in a Behavioral Health role.
|
| NP Supporting a Specialty | CheckBox |
Check this box if you are enrolling as a Nurse Practitioner supporting a specialty.
|
| Certified Midwife | CheckBox |
Check this box if you are enrolling as a Certified Midwife.
|
| Prenatal Care Coordinator | CheckBox |
Check this box if you are enrolling as a Prenatal Care Coordinator.
|
| Other | CheckBox |
Check this box if your enrollment role is not listed above and you will specify it in the provided field.
|
| Other enrollment role | Text |
Enter the name of any additional enrollment role not listed above. Fill only if the 'Other' checkbox is 'Yes'.
Depends on:
Other
|
| Enrollment Type and Update Explanation | ||
| New enrollment | RadioButton |
Check this box if you are submitting an initial (new) enrollment.
|
| Update (fill out updated information ONLY) | RadioButton |
Check this box if you are submitting an update and will provide only the information that has changed.
|
| Update Explanation | Text |
Enter a description of the information that is being updated in this enrollment. Fill only if the 'Update (fill out updated information ONLY)' is 'Yes'.
Depends on:
Update (fill out updated information ONLY)
|
| Ethnicity | ||
| Asian | CheckBox |
Check this box if the practitioner’s ethnicity is Asian.
|
| African American/Black | CheckBox |
Check this box if the practitioner’s ethnicity is African American/Black.
|
| Caucasian/White | CheckBox |
Check this box if the practitioner’s ethnicity is Caucasian/White.
|
| Hispanic/Latino | CheckBox |
Check this box if the practitioner’s ethnicity is Hispanic/Latino.
|
| Native American | CheckBox |
Check this box if the practitioner’s ethnicity is Native American.
|
| Pacific Islander | CheckBox |
Check this box if the practitioner’s ethnicity is Pacific Islander.
|
| Other (please specify) | CheckBox |
Check this box if the practitioner’s ethnicity is not listed above; specify the ethnicity in the adjacent field.
|
| Ethnicity – Other (please specify) | Text |
Enter the specific ethnicity when Other is selected. Fill only if the 'Other (please specify)' is 'Yes'.
Depends on:
Other (please specify)
|
| First Practice Location Accessibility Accommodations | ||
| First Practice Location Building – Yes | RadioButton |
Check this box if the first practice location offers accessible building accommodations.
|
| First Practice Location Building – No | RadioButton |
Check this box if the first practice location does not offer accessible building accommodations.
|
| First Practice Location Parking – Yes | RadioButton |
Check this box if the first practice location offers accessible parking accommodations.
|
| First Practice Location Parking – No | RadioButton |
Check this box if the first practice location does not offer accessible parking accommodations.
|
| First Practice Location Restroom – Yes | RadioButton |
Check this box if the first practice location offers accessible restroom accommodations.
|
| First Practice Location Restroom – No | RadioButton |
Check this box if the first practice location does not offer accessible restroom accommodations.
|
| First Practice Location Accessibility Accommodation – Other | Text |
Enter any additional accessibility accommodations offered at this practice location that are not covered by the Building, Parking, or Restroom options.
|
| First Practice Location Basic Info | ||
| First Practice Group Name | Text |
Enter the official name of the practice group at the first practice location where you will see IHCP members.
|
| First Practice Location NP | RadioButton |
Check this box if this practice location uses a Nurse Practitioner.
|
| First Practice Location PA | RadioButton |
Check this box if this practice location uses a Physician Assistant.
|
| First Practice Location N/A | RadioButton |
Check this box if this practice location does not use a Nurse Practitioner or Physician Assistant.
|
| First Service Location Address | Text |
Provide the full street address, including the ZIP+4 code, for the first practice location.
|
| First Primary Phone | Text |
Enter the main telephone number for the first practice location office.
|
| First Primary Fax | Text |
Enter the main fax number for the first practice location office.
|
| First Practice Location Assign Membership to Location - Yes | RadioButton |
Check this box if, as a Primary Medical Provider (PMP), you want to assign IHCP membership to this practice location.
|
| First Practice Location Assign Membership to Location - No | RadioButton |
Check this box if, as a Primary Medical Provider (PMP), you do not want to assign IHCP membership to this practice location.
|
| First Practice Location Disability Services | ||
| First Practice Location Text Telephony (TTY) - Yes | RadioButton |
Check this box if the practice location offers text telephony (TTY) services for people with disabilities.
|
| First Practice Location Text Telephony (TTY) - No | RadioButton |
Check this box if the practice location does not offer text telephony (TTY) services for people with disabilities.
|
| First Practice Location American Sign Language - Yes | RadioButton |
Check this box if the practice location provides American Sign Language services for people with disabilities.
|
| First Practice Location American Sign Language - No | RadioButton |
Check this box if the practice location does not provide American Sign Language services for people with disabilities.
|
| First Practice Location Mental/Physical Impairment Services - Yes | RadioButton |
Check this box if the practice location offers mental or physical impairment services for people with disabilities.
|
| First Practice Location Mental/Physical Impairment Services - No | RadioButton |
Check this box if the practice location does not offer mental or physical impairment services for people with disabilities.
|
| First Practice Location Other Disability Service | Text |
Enter any additional disability-related service offered at the first practice location that is not listed among the predefined options.
|
| First Practice Location IDs and Contact | ||
| First Practice Location Office Contact Name | Text |
Enter the full name of the office contact person at the first practice location.
|
| First Practice Location Office Contact Email | Text |
Enter the email address of the office contact person at the first practice location.
|
| First Practice Location County | Text |
Enter the county where the first practice location is located.
|
| First Practice Location Group IHCP Provider ID | Text |
Enter the IHCP Provider ID for the group at the first practice location. This is not practitioner’s IHCP Provider ID
|
| First Practice Location Group NPI | Text |
Enter the National Provider Identifier (NPI) for the group at the first practice location.
|
| First Practice Location Taxonomies | Text |
Enter the taxonomy code(s) that classify the group's specialties at the first practice location.
|
| First Practice Location Medicare Group Number | Text |
Enter the Medicare group number used for billing at the first practice location.
|
| First Practice Location Languages | ||
| First Practice Location Language: Spanish | CheckBox |
Check this box if your first practice location’s office is fluent in Spanish.
|
| First Practice Location Language: Mandarin | CheckBox |
Check this box if your first practice location’s office is fluent in Mandarin.
|
| First Practice Location Language: French | CheckBox |
Check this box if your first practice location’s office is fluent in French.
|
| First Practice Location Language: Burmese (dialect) | CheckBox |
Check this box if your first practice location’s office is fluent in Burmese (dialect).
|
| First Practice Location Burmese Dialect | Text |
Enter the specific Burmese dialect in which the office is fluent. Fill only if the 'Burmese, dialect' checkbox is Yes.
Depends on:
First Practice Location Language: Burmese (dialect)
|
| First Practice Location Language: Russian | CheckBox |
Check this box if your first practice location’s office is fluent in Russian.
|
| First Practice Location Language: Other (please specify) | CheckBox |
Check this box if your first practice location’s office is fluent in a language not listed above, and specify it in the field provided.
|
| First Practice Location Other Language | Text |
Enter any other language in which the office is fluent that is not listed above. Fill only if the 'Other (please specify)' checkbox is Yes.
Depends on:
First Practice Location Language: Other (please specify)
|
| First Practice Location Office Hours | ||
| First Practice Location Monday Office Hours | Text |
Enter the regular office hours for Monday at the first practice location.
|
| First Practice Location Tuesday Office Hours | Text |
Enter the regular office hours for Tuesday at the first practice location.
|
| First Practice Location Wednesday Office Hours | Text |
Enter the regular office hours for Wednesday at the first practice location.
|
| First Practice Location Thursday Office Hours | Text |
Enter the regular office hours for Thursday at the first practice location.
|
| First Practice Location Friday Office Hours | Text |
Enter the regular office hours for Friday at the first practice location.
|
| First Practice Location Saturday Office Hours | Text |
Enter the regular office hours for Saturday at the first practice location.
|
| First Practice Location Sunday Office Hours | Text |
Enter the regular office hours for Sunday at the first practice location.
|
| First Practice Location Public Transportation | ||
| First Practice Location Bus: Yes | RadioButton |
Check this box if the first practice location is accessible by bus.
|
| First Practice Location Bus: No | RadioButton |
Check this box if the first practice location is not accessible by bus.
|
| First Practice Location Subway: Yes | RadioButton |
Check this box if the first practice location is accessible by subway.
|
| First Practice Location Subway: No | RadioButton |
Check this box if the first practice location is not accessible by subway.
|
| First Practice Location Regional Train: Yes | RadioButton |
Check this box if the first practice location is accessible by regional train.
|
| First Practice Location Regional Train: No | RadioButton |
Check this box if the first practice location is not accessible by regional train.
|
| First Practice Location Other Public Transportation | Text |
Enter any additional forms of public transportation available to reach the first practice location that are not listed (bus, subway, or regional train).
|
| First Practice Location Site Features | ||
| First Practice Location – Offer Weekend Hours: Yes | RadioButton |
Check this box if your first practice location offers weekend hours.
|
| First Practice Location – Offer Weekend Hours: No | RadioButton |
Check this box if your first practice location does not offer weekend hours.
|
| First Practice Location – Offer Evening Hours: Yes | RadioButton |
Check this box if your first practice location offers evening hours.
|
| First Practice Location – Offer Evening Hours: No | RadioButton |
Check this box if your first practice location does not offer evening hours.
|
| First Practice Location – Serve CSHCN (Children with Special Needs): Yes | RadioButton |
Check this box if your first practice location serves children with special health care needs.
|
| First Practice Location – Serve CSHCN (Children with Special Needs): No | RadioButton |
Check this box if your first practice location does not serve children with special health care needs.
|
| Group Identifiers | ||
| County | Text |
Enter the name of the county in which this primary practice location is located.
|
| Group IHCP Provider ID | Text |
Enter the Indiana Health Coverage Programs (IHCP) provider identification number assigned to the practice group.
|
| Group NPI | Text |
Enter the National Provider Identifier (NPI) number for the practice group.
|
| Taxonomies | Text |
List the taxonomy code(s) that describe the services or specialties of the practice group, separated by commas.
|
| Medicare Group Number | Text |
Enter the Medicare billing group number associated with the practice group.
|
| Hospital Privileges | ||
| Hospital Privileges: Yes | RadioButton |
Check this box if the practitioner has hospital privileges.
|
| Hospital Privileges: No | RadioButton |
Check this box if the practitioner does not have hospital privileges.
|
| Hospital Name 1 | Text |
Enter the name of the first hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Hospital Address 1 | Text |
Enter the address of the first hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Hospital Name 2 | Text |
Enter the name of the second hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Hospital Address 2 | Text |
Enter the address of the second hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Hospital Name 3 | Text |
Enter the name of the third hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Hospital Address 3 | Text |
Enter the address of the third hospital where you hold privileges. Fill only if the 'Hospital Privileges?' is 'Yes'.
Depends on:
Hospital Privileges: Yes
|
| Languages Spoken Other Than English | ||
| Spanish | CheckBox |
Check this box if the office is fluent in Spanish.
|
| Mandarin | CheckBox |
Check this box if the office is fluent in Mandarin.
|
| French | CheckBox |
Check this box if the office is fluent in French.
|
| Burmese (dialect) | CheckBox |
Check this box if the office is fluent in Burmese; specify the dialect.
|
| Burmese Dialect | Text |
Specify the dialect of the Burmese language spoken. Fill only if the 'Burmese, dialect' is 'Yes'.
Depends on:
Burmese (dialect)
|
| Russian | CheckBox |
Check this box if the office is fluent in Russian.
|
| Other (please specify) | CheckBox |
Check this box if the office is fluent in another language not listed above and specify the language.
|
| Other Language(s) Specify | Text |
Enter any other language spoken besides English. Fill only if the 'Other (please specify)' is 'Yes'.
Depends on:
Other (please specify)
|
| Mailing Address | ||
| Mailing Address Same as Primary Practice Address – Yes | RadioButton |
Check this box if the mailing address is the same as the primary practice address.
|
| Mailing Address Same as Primary Practice Address – No | RadioButton |
Check this box if the mailing address is different from the primary practice address.
|
| Mailing Address | Text |
Enter the full mailing address where you want to receive correspondence, including street address, city, state, and ZIP code. Fill only if the 'Mailing Address Same as Primary Practice Address?' is 'No'.
Depends on:
Mailing Address Same as Primary Practice Address – No
|
| OB/GYN Scope of Practice | ||
| All Women (OB/GYN) – Yes | RadioButton |
Check this box if you provide services exclusively to pregnant and nonpregnant female members as an OB/GYN PMP. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| All Women (OB/GYN) – No | RadioButton |
Check this box if you do not provide services exclusively to pregnant and nonpregnant female members as an OB/GYN PMP. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| OB Only (OB/GYN) – Yes | RadioButton |
Check this box if you provide obstetric services only as an OB/GYN PMP. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| OB Only (OB/GYN) – No | RadioButton |
Check this box if you do not provide obstetric services only as an OB/GYN PMP. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| OB (Family Practitioners) – Yes | RadioButton |
Check this box if you are a family practitioner providing obstetric services. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| OB (Family Practitioners) – No | RadioButton |
Check this box if you are not a family practitioner providing obstetric services. Fill only if the 'PMP with Panel' is 'Yes'.
Depends on:
PMP with Panel
|
| Office Hours (Weekly) | ||
| Monday Office Hours | Text |
Enter the office's hours of operation for Monday (e.g., 8:00 AM – 5:00 PM).
|
| Tuesday Office Hours | Text |
Enter the office's hours of operation for Tuesday (e.g., 8:00 AM – 5:00 PM).
|
| Wednesday Office Hours | Text |
Enter the office's hours of operation for Wednesday (e.g., 8:00 AM – 5:00 PM).
|
| Thursday Office Hours | Text |
Enter the office's hours of operation for Thursday (e.g., 8:00 AM – 5:00 PM).
|
| Friday Office Hours | Text |
Enter the office's hours of operation for Friday (e.g., 8:00 AM – 5:00 PM).
|
| Saturday Office Hours | Text |
Enter the office's hours of operation for Saturday (e.g., 8:00 AM – 5:00 PM).
|
| Sunday Office Hours | Text |
Enter the office's hours of operation for Sunday (e.g., 8:00 AM – 5:00 PM).
|
| Operating Hours & Special Needs Services | ||
| Offer Weekend Hours – Yes | RadioButton |
Check if the site offers weekend hours.
|
| Offer Weekend Hours – No | RadioButton |
Check if the site does not offer weekend hours.
|
| Offer Evening Hours – Yes | RadioButton |
Check if the site offers evening hours.
|
| Offer Evening Hours – No | RadioButton |
Check if the site does not offer evening hours.
|
| Serve CSHCN (Children w/Special Needs) – Yes | RadioButton |
Check if the site serves children with special health care needs.
|
| Serve CSHCN (Children w/Special Needs) – No | RadioButton |
Check if the site does not serve children with special health care needs.
|
| Pay-To Information | ||
| Billing Name | Text |
Enter the legal or official name under which invoices should be billed.
|
| Taxpayer ID Number (TIN) | Text |
Provide the nine-digit Taxpayer Identification Number used for billing and remittance purposes.
|
| Billing (Pay-To) Address | Text |
Enter the full street address, city, state, and ZIP code where payment should be sent.
|
| Billing Phone | Text |
Provide the primary telephone number for billing and payment inquiries.
|
| Billing Contact Name | Text |
Enter the name of the individual responsible for billing at the pay-to address.
|
| Billing Contact Email | Text |
Provide the email address for the billing contact for electronic correspondence.
|
| Personal Demographic Info | ||
| Social Security Number | Text |
Enter the practitioner’s nine-digit Social Security Number.
|
| Date of Birth | Date |
Enter the practitioner’s date of birth in MM/DD/YYYY format.
|
| Male | RadioButton |
Check this box if the practitioner’s gender is male.
|
| Female | RadioButton |
Check this box if the practitioner’s gender is female.
|
| PMP Panel Size by Program | ||
| Maximum membership (panel size) accepted (PMPs only) | Number |
Maximum membership (panel size) accepted (PMPs only)
|
| PMP Panel Size – Hoosier Healthwise | Number |
Enter the maximum number of members the practitioner’s PMP accepts for the Hoosier Healthwise program.
|
| PMP Panel Size – Healthy Indiana Plan (HIP) | Number |
Enter the maximum number of members the practitioner’s PMP accepts for the Healthy Indiana Plan (HIP).
|
| PMP Panel Size – Hoosier Care Connect | Number |
Enter the maximum number of members the practitioner’s PMP accepts for the Hoosier Care Connect program.
|
| Please enter Pathways | Number |
Enter the maximum number of members the practitioner’s PMP accepts for the Indiana PathWays for Aging program.
|
| Practice Group Basic Info | ||
| Practice Group Name | Text |
Enter the official name of the practice group at this primary practice location.
|
| NP | RadioButton |
Check this box if the practice location uses a Nurse Practitioner.
|
| PA | RadioButton |
Check this box if the practice location uses a Physician Assistant.
|
| N/A | RadioButton |
Check this box if this location uses neither a Nurse Practitioner nor a Physician Assistant.
|
| Practice Type Selection | ||
| Individual | RadioButton |
Check this box if the practice type associated with this enrollment is Individual.
|
| Group | RadioButton |
Check this box if the practice type associated with this enrollment is Group.
|
| FQHC | RadioButton |
Check this box if the practice type associated with this enrollment is Federally Qualified Health Center (FQHC).
|
| RHC | RadioButton |
Check this box if the practice type associated with this enrollment is Rural Health Clinic (RHC).
|
| Other Clinic (Type) | RadioButton |
Check this box if the practice type associated with this enrollment is another clinic type not listed; specify the type.
|
| Urgent Care | CheckBox |
Check this box if the practice type associated with this enrollment is Urgent Care.
|
| Health Department | CheckBox |
Check this box if the practice type associated with this enrollment is Health Department.
|
| Practitioner Contact | ||
| Practitioner Email Address | Text |
Provide the practitioner’s email address for correspondence regarding this enrollment.
|
| Practitioner Fax Number | Text |
Provide the practitioner’s fax number for sending and receiving faxed documents.
|
| Practitioner Phone Number | Text |
Provide the practitioner’s primary phone number for voice contact regarding this enrollment.
|
| Practitioner Degree | ||
| MD | RadioButton |
Check this box if the practitioner’s degree is MD.
|
| DO | RadioButton |
Check this box if the practitioner’s degree is DO.
|
| DMD | RadioButton |
Check this box if the practitioner’s degree is DMD.
|
| DPM | RadioButton |
Check this box if the practitioner’s degree is DPM.
|
| CRNA | RadioButton |
Check this box if the practitioner’s degree is CRNA.
|
| NP | RadioButton |
Check this box if the practitioner’s degree is NP.
|
| CNM | RadioButton |
Check this box if the practitioner’s degree is CNM.
|
| Other | RadioButton |
Check this box if the practitioner’s degree is not listed and specify it in the field provided.
|
| Other Degree Specification | Text |
Enter the specific practitioner degree when the "Other" option is selected in the Practitioner Degree section. Fill only if the 'Practitioner Degree – Other' is 'Yes'.
Depends on:
Other
|
| Practitioner Name and CAQH | ||
| CAQH Number | Text |
Enter the practitioner’s Council for Affordable Quality Healthcare (CAQH) identification number.
|
| Practitioner First Name | Text |
Enter the practitioner’s legal first name as it appears on official documents.
|
| Middle Initial | Text |
Enter the practitioner’s middle initial.
|
| Practitioner Last Name | Text |
Enter the practitioner’s legal last name as it appears on official documents.
|
| Name Suffix | Text |
Enter the practitioner’s name suffix (e.g., Jr., Sr., III) if applicable.
|
| Practitioner or Practice Exclusions Disclosure | ||
| Exclusion Disclosure Explanation | Text |
Enter an explanation, including dates, for any occasions the practitioner or practice was excluded from Medicaid or Medicare.
|
| Practitioner Status | ||
| Locum Tenem | CheckBox |
Check this box if you are practicing as a locum tenens practitioner.
|
| Hospital-Based Physician | CheckBox |
Check this box if you practice as a hospital-based physician.
|
| Hospitalist | CheckBox |
Check this box if you serve in the role of a hospitalist.
|
| Professional Identifiers | ||
| National Provider Identifier (NPI) | Text |
Enter the practitioner’s 10-digit National Provider Identifier issued by CMS.
|
| Taxonomies | Text |
List all applicable taxonomy codes that describe the practitioner’s specialties or classifications.
|
| DEA Number | Text |
Enter the practitioner’s Drug Enforcement Administration registration number.
|
| CSR Number | Text |
Enter the practitioner’s Controlled Substances Registration (CSR) number.
|
| License Number and State | Text |
Provide the practitioner’s professional license number or BCBA Certificate Number, followed by the two-letter state abbreviation where it was issued.
|
| UPIN | Text |
Enter the practitioner’s Unique Physician Identification Number assigned by CMS.
|
| IHCP Provider ID | Text |
If applicable, enter the provider ID previously assigned by the Indiana Health Coverage Programs managed care entity.
|
| Program Selection | ||
| Healthy Indiana Plan (HIP) | CheckBox |
Check this box to indicate this form applies to the Healthy Indiana Plan (HIP).
|
| Hoosier Care Connect | CheckBox |
Check this box to indicate this form applies to Hoosier Care Connect.
|
| Hoosier Healthwise | CheckBox |
Check this box to indicate this form applies to Hoosier Healthwise.
|
| Indiana PathWays for Aging | CheckBox |
Check this box to indicate this form applies to Indiana PathWays for Aging.
|
| Public Transportation Access | ||
| Bus – Yes | RadioButton |
Check this box if the site is accessible by bus.
|
| Bus – No | RadioButton |
Check this box if the site is not accessible by bus.
|
| Subway – Yes | RadioButton |
Check this box if the site is accessible by subway.
|
| Subway – No | RadioButton |
Check this box if the site is not accessible by subway.
|
| Regional Train – Yes | RadioButton |
Check this box if the site is accessible by regional train.
|
| Regional Train – No | RadioButton |
Check this box if the site is not accessible by regional train.
|
| Other Public Transportation Mode | Text |
Provide any other form of public transportation accessible at this location not listed among bus, subway, or regional train.
|
| Relationship Privileges (No Hospital) | ||
| Relationship Privileges Yes | RadioButton |
Check this box if you have relationship privileges when you do not have hospital privileges. Fill only if the 'Hospital Privileges?' is 'No'.
Depends on:
Hospital Privileges: No
|
| Relationship Privileges No | RadioButton |
Check this box if you do not have relationship privileges when you do not have hospital privileges. Fill only if the 'Hospital Privileges?' is 'No'.
Depends on:
Hospital Privileges: No
|
| Relationship Privileges Physician | Text |
Enter the full name of the physician with whom you have a relationship privilege agreement. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Relationship Privileges Hospital | Text |
Enter the name of the hospital associated with your relationship privileges. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Relationship Privileges Address | Text |
Provide the complete address of the hospital where you hold relationship privileges, including street, city, state, and ZIP code. Fill only if the 'Relationship Privileges?' is 'Yes'.
Depends on:
Relationship Privileges Yes
|
| Second Practice Location Accessibility Accommodations | ||
| Second Practice Location Building Accessible – Yes | RadioButton |
Check this box if the building at the second practice location offers accessible accommodations.
|
| Second Practice Location Building Accessible – No | RadioButton |
Check this box if the building at the second practice location does not offer accessible accommodations.
|
| Second Practice Location Parking Accessible – Yes | RadioButton |
Check this box if the parking at the second practice location offers accessible accommodations.
|
| Second Practice Location Parking Accessible – No | RadioButton |
Check this box if the parking at the second practice location does not offer accessible accommodations.
|
| Second Practice Location Restroom Accessible – Yes | RadioButton |
Check this box if the restroom at the second practice location offers accessible accommodations.
|
| Second Practice Location Restroom Accessible – No | RadioButton |
Check this box if the restroom at the second practice location does not offer accessible accommodations.
|
| Second Practice Location Other Accessible Accommodation | Text |
Specify any additional accessible accommodation provided at the second practice location that is not covered by the Building, Parking, or Restroom options.
|
| Second Practice Location Basic Info | ||
| Second Practice Location Group Name | Text |
Enter the name of the practice group for the second additional practice location.
|
| Second Practice Location NP | RadioButton |
Check this box if the second practice location uses a Nurse Practitioner.
|
| Second Practice Location PA | RadioButton |
Check this box if the second practice location uses a Physician Assistant.
|
| Second Practice Location N/A | RadioButton |
Check this box if using a Nurse Practitioner or Physician Assistant is not applicable for the second practice location.
|
| Second Practice Location Service Address | Text |
Provide the full service location address for the second practice location, including the ZIP+4 code.
|
| Second Practice Location Primary Phone | Text |
Enter the primary telephone number for the second practice location.
|
| Second Practice Location Primary Fax | Text |
Enter the primary fax number for the second practice location.
|
| Second Practice Location Assign PMP membership – Yes | RadioButton |
Check this box to assign PMP membership to this second practice location.
|
| Second Practice Location Assign PMP membership – No | RadioButton |
Check this box to not assign PMP membership to this second practice location.
|
| Second Practice Location Disability Services | ||
| Second Practice Location Text Telephony (TTY) Yes | RadioButton |
Check this box if the second practice location offers Text Telephony (TTY) services.
|
| Second Practice Location Text Telephony (TTY) No | RadioButton |
Check this box if the second practice location does not offer Text Telephony (TTY) services.
|
| Second Practice Location American Sign Language Yes | RadioButton |
Check this box if the second practice location offers American Sign Language services.
|
| Second Practice Location American Sign Language No | RadioButton |
Check this box if the second practice location does not offer American Sign Language services.
|
| Second Practice Location Mental/Physical Impairment Services Yes | RadioButton |
Check this box if the second practice location offers Mental/Physical Impairment Services.
|
| Second Practice Location Mental/Physical Impairment Services No | RadioButton |
Check this box if the second practice location does not offer Mental/Physical Impairment Services.
|
| Second Practice Location Other Disability Services | Text |
Enter any other services for people with disabilities offered at the second practice location that are not listed above. Fill only if the 'Does this site offer other services for people with disabilities?' is 'Yes'.
|
| Second Practice Location IDs and Contact | ||
| Second Practice Location Office Contact Name | Text |
Enter the name of the primary office contact person for the second practice location. This is not practitioner’s legal first name
|
| Second Practice Location Office Contact Email | Text |
Enter the email address of the primary office contact for the second practice location.
|
| Second Practice Location County | Text |
Enter the county in which the second practice location is physically located.
|
| Second Practice Location Group IHCP Provider ID | Text |
Enter the IHCP provider identification number assigned to the provider group at the second practice location. This is not practitioner’s IHCP Provider ID
|
| Second Practice Location Group NPI | Text |
Enter the National Provider Identifier (NPI) for the provider group at the second practice location.
|
| Second Practice Location Taxonomies | Text |
List the taxonomy code(s) that describe the specialty classification(s) for the provider group at the second practice location.
|
| Second Practice Location Medicare Group Number | Text |
Enter the Medicare group number assigned to the provider group at the second practice location.
|
| Second Practice Location Languages | ||
| Second Practice Location Language: Spanish | CheckBox |
Check this box if the office at your second practice location is fluent in Spanish.
|
| Second Practice Location Language: Mandarin | CheckBox |
Check this box if the office at your second practice location is fluent in Mandarin.
|
| Second Practice Location Language: French | CheckBox |
Check this box if the office at your second practice location is fluent in French.
|
| Second Practice Location Language: Burmese (dialect) | CheckBox |
Check this box if the office at your second practice location is fluent in Burmese; indicate the dialect.
|
| Second Practice Location Burmese Dialect | Text |
Specify the Burmese dialect the office is fluent in at the second practice location.
|
| Second Practice Location Language: Russian | CheckBox |
Check this box if the office at your second practice location is fluent in Russian.
|
| Second Practice Location Language: Other (please specify) | CheckBox |
Check this box if the office at your second practice location is fluent in a language not listed above and specify the language.
|
| Second Practice Location Office Hours | ||
| Second Practice Location Office Hours - Monday | Text |
Enter the hours during which the office is open on Monday at the second practice location.
|
| Second Practice Location Office Hours - Tuesday | Text |
Enter the hours during which the office is open on Tuesday at the second practice location.
|
| Second Practice Location Office Hours - Wednesday | Text |
Enter the hours during which the office is open on Wednesday at the second practice location.
|
| Second Practice Location Office Hours - Thursday | Text |
Enter the hours during which the office is open on Thursday at the second practice location.
|
| Second Practice Location Office Hours - Friday | Text |
Enter the hours during which the office is open on Friday at the second practice location.
|
| Second Practice Location Office Hours - Saturday | Text |
Enter the hours during which the office is open on Saturday at the second practice location.
|
| Second Practice Location Office Hours - Sunday | Text |
Enter the hours during which the office is open on Sunday at the second practice location.
|
| Second Practice Location Public Transportation | ||
| Second practice location – Bus: Yes | RadioButton |
Select this box if the second practice location is accessible by bus.
|
| Second practice location – Bus: No | RadioButton |
Select this box if the second practice location is not accessible by bus.
|
| Second practice location – Subway: Yes | RadioButton |
Select this box if the second practice location is accessible by subway.
|
| Second practice location – Subway: No | RadioButton |
Select this box if the second practice location is not accessible by subway.
|
| Second practice location – Regional Train: Yes | RadioButton |
Select this box if the second practice location is accessible by regional train.
|
| Second practice location – Regional Train: No | RadioButton |
Select this box if the second practice location is not accessible by regional train.
|
| Second Practice Location Public Transportation Other | Text |
Specify any additional public transportation options available at the second practice location that are not listed under bus, subway, or regional train.
|
| Second Practice Location Site Features | ||
| Second Practice Location - Offer weekend hours: Yes | RadioButton |
Check if this practice location offers weekend hours.
|
| Second Practice Location - Offer weekend hours: No | RadioButton |
Check if this practice location does not offer weekend hours.
|
| Second Practice Location - Offer evening hours: Yes | RadioButton |
Check if this practice location offers evening hours.
|
| Second Practice Location - Offer evening hours: No | RadioButton |
Check if this practice location does not offer evening hours.
|
| Second Practice Location - Serve CSHCN (Children w/Special Needs): Yes | RadioButton |
Check if this practice location serves children with special health care needs.
|
| Second Practice Location - Serve CSHCN (Children w/Special Needs): No | RadioButton |
Check if this practice location does not serve children with special health care needs.
|
| Service Location and Contact Info | ||
| Service Location Address | Text |
Enter the full street address of the primary service location, including city, state, and ZIP+4 code.
|
| Primary Phone | Text |
Provide the main telephone number where this service location can be reached, including area code.
|
| Primary Fax | Text |
Provide the main fax number for this service location, including area code.
|
| Assign membership to this location – Yes | RadioButton |
Check this box if the primary medical provider should be assigned membership to this service location.
|
| Assign membership to this location – No | RadioButton |
Check this box if the primary medical provider should not be assigned membership to this service location.
|
| Office Contact Name | Text |
Enter the full name of the primary office contact person responsible for this location.
|
| Office Contact Email | Text |
Provide the email address of the primary office contact person for this location.
|
| Specialty and NP Support | ||
| Primary Specialty | Text |
Enter the practitioner’s primary clinical specialty for IHCP MCE enrollment.
|
| Secondary Specialty | Text |
Enter the practitioner’s secondary clinical specialty, if applicable.
|
| NP – Specialty-Supported? Yes | RadioButton |
Check this box if the nurse practitioner is specialty-supported for the listed specialties. Fill only if the 'NP Supporting a Specialty' is 'Yes'.
Depends on:
NP Supporting a Specialty
|
| NP – Specialty-Supported? No | RadioButton |
Check this box if the nurse practitioner is not specialty-supported for the listed specialties. Fill only if the 'NP Supporting a Specialty' is 'Yes'.
Depends on:
NP Supporting a Specialty
|