Indiana Care Select Provider Forms

MDwise Provider Forms

Full Panel Add Form
Hold Panel Add Request Form
Pre-Birth Selection Form
Provider Request for Member Reassignment
Addendum
Enrollment Form/Schedule A
CareConnect Acknowledgement Form
Member Intervention Education Form
W-9 Request for Taxpayer Identification Number
Member Ward/Foster Doctor Change Address Form
Member Asthma Action Plan Form
Home and Community Based Services (HCBS) Waiver

Care Select

RBMC Primary Medical Provider Disenrollment Cover Form without Reenrollment
Managed Care PMP Disenrollment with Reenrollment Form
Managed Care PMP Enrollment Update Form
Managed Care PMP Panel Limit and Panel Hold Form

Prior Authorization

Prior Authorization - System Update Request Form
Prior Review and Authorization Dental Request Form
Prior Review and Authorization Request Form

Pharmacy?

For pharmacy forms and resources, please visit the pharmacy area of our website.

Questions?

Please contact MDwise Provider Relations at 1.866.440.2449 or 317.829.8189 if you are in the Indianapolis area.

 

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