Get Indiana Ihcp Provider Recertification Form 2012
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How to fill out the Indiana IHCP Provider Recertification Form online
The Indiana IHCP Provider Recertification Form is essential for enrolled providers to update their expiring licenses and certifications, ensuring their ongoing eligibility for the Indiana Health Coverage Programs. This guide provides a step-by-step approach to assist you in filling out the form correctly and efficiently online.
Follow the steps to correctly complete the Indiana IHCP Provider Recertification Form.
- Press the ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin filling out the form by entering your provider's legal name in the first field. Ensure that it is printed accurately to avoid issues during processing.
- Next, enter your Legacy Provider Identifier (LPI) along with the Service Location Alpha Suffix in the designated fields.
- Input your National Provider Identifier (NPI) and Taxonomy in the following sections to identify your specific provider category.
- Provide your ZIP + 4 and Taxpayer Identification Number (TIN) in the respective fields to ensure proper identification.
- If you are part of a group or clinic, complete the sections for Rendering Provider Information by adding the rendering provider's name, LPI, and NPI.
- Indicate if there have been no linkage changes since the last recertification period by checking the appropriate box.
- If there have been linkage changes, fill out the relevant fields detailing the rendering provider linkage changes, including any linkages that are no longer active.
- For common carrier transportation providers, input the Interstate Carrier’s USDOT or Motor Carrier Docket Number and the Indiana Identification Number.
- Complete the contact information section by providing the contact person's name, telephone number, and email address for any queries related to the form.
- In the authorized signature section, the authorized official must provide their name, title, signature, and the date. This is crucial for processing the form.
- Once all fields are completed, perform a quality check to ensure all necessary documentation is included. After confirming accuracy, you may save changes, download, print, or share the form as required.
Begin your online recertification process now by filling out the Indiana IHCP Provider Recertification Form.
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IHCP Medicaid, or the Indiana Health Coverage Programs, encompasses the Medicaid services provided to eligible individuals in Indiana. It offers a range of health services including preventive care, hospital stays, and prescription medications. Eligible providers must complete the Indiana IHCP Provider Recertification Form to participate. This program aims to improve health outcomes for Indiana residents by ensuring access to medical care.
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