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  • Ihcp Personal Representative Authorization Form - Indiana Medicaid

Get Ihcp Personal Representative Authorization Form - Indiana Medicaid

Indiana Health Coverage Programs P E R S O N A L R E P R E S E N T A T I V E A U T H O R I Z A T I O N The individual (member) who is the subject of the health information maintained by the Indiana.

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Establishing an Authorized Representative with the state The form needs to be signed by you and the person you authorize as your representative. It should then be filed with the state by fax to 800-403-0864 or delivered by mail or in person to your local county office.

Please call 1-844-607-2831 to obtain prior authorization for emergency admissions.

The Indiana Health Coverage Programs (IHCP) requires prior authorization (PA) for certain covered services to document the medical necessity for those services.

If a claim is denied during the administrative review process, the claim should be submitted for appeal. Customer Assistance at 1-800-457-4587 or submit a written inquiry or secure correspondence per the instructions on the Indiana Medicaid website.

Call us at 1-877-822-7196 or in the Indianapolis area 317-822-7196. There are representatives that can help you.

Change of Ownership The following must be submitted along with the enrollment application: Appropriate licensure or other supporting documentation. A copy of a purchase agreement, bill of sale, or other documentation to verify the CHOW.

Contacts for Members Not Enrolled in a Health Plan: Traditional Medicaid (Not enrolled in a health plan)Member Services800-457-4584Pharmacy Services855-577-6317

Provider Enrollment Inquiries If you have questions about IHCP provider enrollment, enrollment status or provider profile updates, call Customer Assistance at 800-457-4584 and select option 2, and then option 1 to check provider enrollment status or option 3 to update provider enrollment information.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232